Please review our research, where we invited patients to co-author their medical records by completing a PreHistory. 263 patients, age 14-94, completed a PreHIstory in preparation for a visit with their family doctor. Patients, often with the help of a family member, friend or caregiver, completed nearly 30 questions on a 2 ½ page PreHx form. As per our research protocol, patients presented their PreHistory at the office check-in window in order to participate in the study. Staff members scanned the PreHx as a pdf in to the electronic health record (EHR) and transcribed the content into the appropriate fields of the History component of the EHR’s encounter note. This allowed the patient’s own words to populate the medical record before meeting face-to-face with the doctor.
Legally, each patient submitted a PreHistory as a “written request to amend the health record according to the HIPAA Privacy Rule” [45 C.F.R. § 164.526]. The medical provider was additionally able to accept the PreHistory as patient generated health data as part of an objective to coordinate care through patient engagement per MACRA.
This paper recognizes that the quality of medical record documentation is not good. Due to time constraints and computer task burdens, medical providers face a near impossible challenge to complete an entire History. The History, medical interview, has about 30 questions defined and structured per CMS 1995 & 1997 Evaluation and Management Documentation Guidelines. It was the purpose of our study to alleviate the medical provider of trying to ask all of these questions, wait for a response, then type/dictate patient responses into the computer. We gave the patient a chance to answer the questions.
Per our research protocol, we collected patient experience surveys before and after the PreHistory encounter. At the check-out window, each patient received a paper copy of the medical record reflective of the visit that just occurred. Patients were instructed to go home, read their medical record, and score it with an anonymous survey.
Patients reported feeling better heard and understood because of completing a PreHistory. They appreciated being given the chance to co-author their record. Many patient reported feeling intimidated by typical rapid-fire questioning during medical visits. By completing a PreHistory in advance of the visit, patients liked being able to consider each question and reflect over an appropriate response. Participants scored their experience as a patient with a satisfaction score of 97%.
One of the most exiting parts of this research is how it changed the patient-provider dynamics during the visit. The doctor was able to enter the room and greet the patient. The doctor then read the patient’s story as documented in the medical record. In less than a minute, the doctor was able read a complete History and understand the patient’s concerns. The doctor was able to reaffirm what he learned by asking the patient, “You are telling me that this and this are going on?” The doctor asked a few detailed questions and then conducted a pertinent Examination. Because both the patient and the doctor were highly engaged, medical decision making readily transformed into shared decision making.
Our mantra for this type of patient-provider relationship is “responsible patients and responsive providers.” We hope this research demonstrated information helps you improve your healthcare and strengthen the relationship with your provider.
HIPAA Privacy Rule
The official full name is the Standards for Privacy of Individually Identifiable Health Information of 2001
MACRA is an acronym for the Medicare Access and CHIP Reauthorization Act of 2015. This law developed a new physician payment formula. Data capture began January 1, 2017 in order to calculate payments for 2019.