Physician-Patient Encounters The Physician Perspective

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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 - PowerPoint PPT Presentation

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Physician-Patient Encounters The Physician Perspective

Physician-Patient Encounters

The Physician PerspectiveMichael Stearns, MD, CPCHIT Consultant

Develop a rapport with the patientEstablish credibility with the patientEstablish the reliability of the patientGather informationFrom the historyFrom the examinationFrom test resultsFrom reports from other providersGet through the examination efficientlyGet paid, if surgical get casesDont get suedDont become subjected to a negative auditHave the patient say good things about you in the community, in particular to the physician who referred the patient to you High Level Physician GoalsBe polite and professionalNot too reservedNot too friendlyAppear knowledgeablePatient may know more about a disease than you do, e.g., if they have been performing on-line researchKeep the patient on task, but interrupt them as little as possibleCan be very challenging

Develop a rapport with the patientBe a good listenerEHRs can interfere with this processDemonstrate familiarity with their complaints and ask insightful questionsCommunicate in a way they can easily understand, without coming across as patronizingEstablish Credibility with the PatientIn some cases you need to interpret information that is provided by the patientSecondary gain (may be a factor, such as what may be seen for potential disability when there is insurance)Psychological issuesEmbellishment tied to:Fears that underlying condition is serious in natureFears that they will not be taken seriously unless they amplify the severity of their symptomsEstablish the Reliability of the PatientUse the history, physical and the results of diagnostic studiesForm an impression of what might be influencing the patients healthIdentify potential emergency conditionsSometimes seconds matterFocus on conditions that can be treated firstBe very wary of making assumptions that could lead to misdiagnosis

Prioritize Nature of VisitTypically a brief statement that starts the noteIncludes:Background demographicsSome background medical informationReason they are being seen, often in the patients own wordsFor 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 structuredClassic description is The reason why the patient is being seen in their own wordsDocumentation guidelines (for reimbursement) state that a CC must be present, but it can be part of the HPI. Chief ComplaintBasically the story behind the visit80% of any diagnosis is made from the HPIIterative and interactive processSeries of questions and answersFollows logical courseRequires expert knowledge of how diseases presentPhysician may develop a short list of diagnoses (in their mind) that he/she is consideringResponses to questions drive next questionSomewhat algorithmicEliminate some conditionsConfirm othersGives weighting to certain conditions over others in many cases

History of Present IllnessMay include relevant past medical informationRelevant medicationsResponses to prior treatmentsUnderlying diseasesPrior injuries or events (e.g., trauma)Family historySocial historyHistory of Present Illness (2)Summary of relevant recent eventsRecent hospitalizationsRecent surgeriesPrior evaluations by other providersStressors that could influence healthE.g., Work-related stressHistory of Present Illness (3)HPI documentation goalsDocument information for purely clinical useReference notes for point of care useFuture visitsInformation to be used for care at other locationsMedicolegal documentationDemonstrate that the standard of care was met via documentationBe wary of template defaults and cloning of informationReimbursement purposesHPI heavily influences coding and reimbursementNeed 1-4 HPI elements OR 3 chronic diseases and their statusesUsed to determine E&M level of service

History of Present Illness (4)Enter complex information and overcome natural language challengesFree text entry via voice recognition, typing or other methodsHowever, this usually results in the loss of structured data (also called discrete data and/or codified data)May be offset by NLP and automated codingTemplates/Macros popular in EHRsNeed to capture as many potential questions as possible through drop down lists with branchesHuge amount of potential information could be neededHPI templates generally are difficult to buildWell constructed templates have the ability to remind physicians of certain questions that should be asked

The HPI and EHRsHPI templates continued:Must take into consideration:Clinical knowledge to aid with documentationMedicolegal considerationsWere all the relevant questions asked and documented in case the care of the patient was to later be challengedCoding and billing questionsNeeds 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 systemsUsually context specificE.g., New patient headache, follow-up diabetes, etc.Usually specialty specificVery different level of detail may be needed depending on specialtyHPIs and EHRs (3)Often the next section of the history and physical (H&P) after HPIMay be entered by the patient, taken by the MA, or in some cases imported electronicallyTypically reviewed by the provider before they see the patientProvider will use information from the section to help with determining the diagnosisPast Medical, Family and Social HistoryOften obtained prior to the patient being seen by the provider and reviewed by the provider before seeing the patientComplete history, regardless of relevancyCan be labor intensive for patient/staff to recordPast medical history usually contains:MedicationsAllergiesCurrent and former illnesses and injuriesSurgeriesHospitalizationsImmunization historyBirth historyOthers

Past Medical HistoryWas a separate sheet in the front of paper chart, used in inpatient records and in some specialtiesHas evolved with advent of EHRs to be central component of patient recordGenerally a subset of information from the past medical history, limited to relevant conditions that are currently activeUse varies markedlyCentral focus of interoperability efforts via CCDProblem ListCan be limited to a screening history of relevant medical conditions in the patients family historyWeighted towards conditions that have known tendency to be passed from one generation to anotherE.g., Huntingtons DiseaseCan have less relevance in elderly patientsWill take on a great deal of new significance in the genomic medicine eraPast Family HistoryUsually includes:OccupationMarital historyLiving situationFamily members when relevantRelationships when relevantAlcohol useDrug useSexual historyOther social factorsSocial HistoryMake sure all relevant information is obtainedMake sure items that could adversely impact patient care are capturedMedicolegal considerations (e.g., missed drug allergy)Important for decision support applications, like e-prescribing CDS toolsNeeds to be placed into correct sections of EHR to be used for E&M codingAll three needed for highest coding levelsAvoid defaults that bring in too much information and falsely elevate coding levelsProvider Considerations for PFSHAs compared to the HPI, this section is much more easily codifiedMore applicable to interoperabilityMedications, problems (usually selected items from the past medical history), allergies and labs are now shared via CCDEHRs and other HIT systems have limited capabilities to import and export this data, but this is rapidly evolvingHIT Considerations for the PFSHImporting data directly from an HIE or other source needs to be done carefullyData can be corruptedE.g., wrong code used and then interpreted incorrectly by receiving systemIncomplete or inaccurate data can impact patient careNegation can corrupt dataUncertainty can corrupt dataData integrity is a rapidly emerging area of HITHIT Considerations for the PSFHEHRMay provide templatesMay require specialty specific templatesE.g., details of prior surgeries for surgical subspecialty like orthopedicsData may be codified at point of captureICD-9-CM in most casesCPT in some instancesSNOMED CT emergingMay need to interact with an immunization module, and state registriesHIT Considerations for PSFH (3)Inventory of current body systemsBasically a screen following the HPI and PFSH to identify any other symptoms or patient identified findings that were not previously addressed in HPITypically about 14 systems are usedE.g., respiratory system, cardiovascular system, etc. Review of SystemsLabor intensiveCan lead to discovery of new information that could markedly impact diagnosis and care decisionsCan also be a time intensive pursuit of information that is not relevant for that specific encounterQuestions 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?Dont miss anything relevant that could impact the care of the patientPatient care concernsMedicolegal concernsEHRs allow for default normals or cloning in ROS; common to see conflicts with HPIGet 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 considerationsROS can be a major workflow considerationPatients can enter the dataVia kiosk, patient portal, personal health record, forms that can be scanned, etc.May need to translate medical information to something patients can consumeMA or other anc

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