Michael Stearns, MD, CPC
HIT Consultant
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Develop a rapport with the patient
Establish credibility with the patient
Establish the reliability of the patient
Gather information
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From
From
From
From
the history
the examination
test results
reports from other providers
Get through the examination efficiently
Get paid, if surgical get cases…
Don’t get sued
Don’t become subjected to a negative audit
Have the patient say good things about you in the
community, in particular to the physician who referred the
patient to you
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Be polite and professional
Not too reserved
Not too friendly
Appear knowledgeable
◦ Patient may know more about a disease than you
do, e.g., if they have been performing on-line
research
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Keep the patient on task, but interrupt them
as little as possible
◦ Can be very challenging…
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Be a good listener
◦ EHRs can interfere with this process
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Demonstrate familiarity with their complaints
and ask insightful questions
Communicate in a way they can easily
understand, without coming across as
patronizing…
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In some cases you need to interpret
information that is provided by the patient
◦ Secondary gain (may be a factor, such as what may
be seen for potential disability when there is
insurance)
◦ Psychological issues
◦ Embellishment tied to:
 Fears that underlying condition is serious in nature
 Fears that they will not be taken seriously unless they
“amplify” the severity of their symptoms
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Use the history, physical and the results of
diagnostic studies
◦ Form an impression of what might be influencing
the patient’s health
◦ Identify potential emergency conditions
 Sometimes seconds matter
◦ Focus on conditions that can be treated first
◦ Be very wary of making assumptions that could lead
to misdiagnosis
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Typically a brief statement that starts the note
Includes:
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For example:
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◦ Background demographics
◦ Some background medical information
◦ Reason they are being seen, often in the patient’s own
words
◦ The patient is a 44-year-old white male with a history of
hypertension and diabetes who presents with “numbness
in my toes.”
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There are multiple variations as to how a CC is
structured
◦ Classic description is “The reason why the patient is
being seen in their own words”
◦ Documentation guidelines (for reimbursement) state that
a CC must be present, but it can be part of the HPI.
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Basically the story behind the visit
80% of any diagnosis is made from the HPI
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Iterative and interactive process
Series of questions and answers
Follows logical course
Requires expert knowledge of how diseases present
Physician may develop a short list of diagnoses (in their
mind) that he/she is considering
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Responses to questions drive next question
Somewhat algorithmic
Eliminate some conditions
Confirm others
Gives weighting to certain conditions over others in many
cases
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May include relevant past medical
information
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Relevant medications
Responses to prior treatments
Underlying diseases
Prior injuries or events (e.g., trauma)
Family history
Social history
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Summary of relevant recent events
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Recent hospitalizations
Recent surgeries
Prior evaluations by other providers
Stressors that could influence health
 E.g., Work-related stress
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HPI documentation goals
◦ Document information for purely clinical use
 Reference notes for point of care use
 Future visits
 Information to be used for care at other locations
◦ Medicolegal documentation
 Demonstrate that the standard of care was met via
documentation
 Be wary of template defaults and cloning of information
◦ Reimbursement purposes
 HPI heavily influences coding and reimbursement
 Need 1-4 HPI elements OR 3 chronic diseases and their
statuses
 Used to determine E&M level of service
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Enter complex information and overcome
natural language challenges
◦ Free text entry via voice recognition, typing or other
methods
 However, this usually results in the loss of structured
data (also called discrete data and/or codified data)
 May be offset by NLP and automated coding
◦ Templates/Macros popular in EHRs
 Need to capture as many potential questions as possible
through drop down lists with branches
 Huge amount of potential information could be needed
 HPI templates generally are difficult to build
 Well constructed templates have the ability to remind
physicians of certain questions that should be asked
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HPI templates continued:
◦ Must take into consideration:
 Clinical knowledge to aid with documentation
 Medicolegal considerations
 Were all the relevant questions asked and documented in
case the care of the patient was to later be challenged
 Coding and billing questions
 Needs 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
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Template models vary widely between EHR
systems
Usually context specific
◦ E.g., New patient headache, follow-up diabetes, etc.
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Usually specialty specific
◦ Very different level of detail may be needed
depending on specialty
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Often the next section of the history and
physical (H&P) after HPI
May be entered by the patient, taken by the
MA, or in some cases imported electronically
Typically reviewed by the provider before they
see the patient
Provider will use information from the section
to help with determining the diagnosis
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Often obtained prior to the patient being seen by
the provider and reviewed by the provider before
seeing the patient
Complete history, regardless of relevancy
Can be labor intensive for patient/staff to record
Past medical history usually contains:
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Medications
Allergies
Current and former illnesses and injuries
Surgeries
Hospitalizations
Immunization history
Birth history
Others
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Was a separate sheet in the front of paper
chart, used in inpatient records and in some
specialties
Has evolved with advent of EHRs to be central
component of patient record
Generally a subset of information from the
past medical history, limited to relevant
conditions that are currently active
Use varies markedly
Central focus of interoperability efforts via
CCD
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Can be limited to a screening history of
relevant medical conditions in the patient’s
family history
Weighted towards conditions that have known
tendency to be passed from one generation
to another
◦ E.g., Huntington’s Disease
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Can have less relevance in elderly patients
Will take on a great deal of new significance
in the genomic medicine era
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Usually includes:
◦ Occupation
◦ Marital history
◦ Living situation
 Family members when relevant
 Relationships when relevant
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Alcohol use
Drug use
Sexual history
Other social factors
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Make sure all relevant information is obtained
Make sure items that could adversely impact
patient care are captured
◦ Medicolegal considerations (e.g., missed drug allergy)
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Important for decision support applications, like
e-prescribing CDS tools
Needs to be placed into correct sections of EHR
to be used for E&M coding
◦ All three needed for highest coding levels
◦ Avoid defaults that bring in too much information and
falsely elevate coding levels
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As compared to the HPI, this section is much
more easily “codified”
More applicable to interoperability
◦ Medications, problems (usually selected items from
the past medical history), allergies and labs are now
shared via CCD
◦ EHRs and other HIT systems have limited
capabilities to import and export this data, but this
is rapidly evolving
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Importing data directly from an HIE or other
source needs to be done carefully
Data can be corrupted
◦ E.g., wrong code used and then interpreted
incorrectly by receiving system
◦ Incomplete or inaccurate data can impact patient
care
 Negation can corrupt data
 Uncertainty can corrupt data
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Data integrity is a rapidly emerging area of
HIT
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EHR
◦ May provide templates
◦ May require specialty specific templates
 E.g., details of prior surgeries for surgical subspecialty
like orthopedics
◦ Data may be codified at point of capture
 ICD-9-CM in most cases
 CPT in some instances
 SNOMED CT emerging
◦ May need to interact with an immunization module,
and state registries
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Inventory of current body systems
Basically a screen following the HPI and PFSH
to identify any other symptoms or patient
identified findings that were not previously
addressed in HPI
Typically about 14 systems are used
◦ E.g., respiratory system, cardiovascular system, etc.
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Labor intensive
Can lead to discovery of new information that
could markedly impact diagnosis and care
decisions
Can also be a time intensive pursuit of
information that is not relevant for that
specific encounter
◦ Questions like “are you experiencing fatigue” are
potentially going to yield a high percentage of
positive responses that the provider may feel
obligated to pursue….
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What is the provider thinking?
◦ Don’t miss anything relevant that could impact the
care of the patient
 Patient care concerns
 Medicolegal concerns
 EHRs allow for default normals or cloning in ROS; common
to see conflicts with HPI
 Get 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
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EHR considerations
◦ ROS can be a major workflow consideration
 Patients can enter the data
 Via kiosk, patient portal, personal health record, forms that
can be scanned, etc.
 May need to translate medical information to something
patients can consume
 MA or other ancillary staff can enter data provided by
patients in writing, or taken directly from the patient
 Provider may take the ROS, but in general they review
information entered by others
◦ Tendency for fraud relatively high in this section due to
lack of interaction with HPI
 Common for finding in HPI to be in conflict with ROS
 Suggests fraud given that ROS defaults are common settings
in EHRs
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Typically includes
◦ Measured vital signs: height, weight, blood
pressure, pulse, respirations
 BMI is calculated
◦ Direct observations of the patient (e.g., skin lesion
on face)
◦ Findings on inspection of the patient (e.g.,
tenderness of the abdomen)
◦ Some test results may be included in the PE (e.g.,
smear of fluids obtained during procedure)
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Can be very specialty specific
Usually area of body targeted is based on the
patient’s presenting complaints
◦ “Full” physical could take 2 hours or more to
complete
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Very data intensive for abnormal findings
◦ Many clinical examination findings have multiple
ways of being described
◦ Eponyms used frequently
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What is the provider thinking?
◦ Don’t miss something that could make a difference
in the patient’s care
◦ Perform an adequate examination of the relevant
organ system, and document it, to demonstrate the
standard of care was met
◦ Document findings in organs system that were
medically relevant to examine and captured for
level of service (E&M) determination (i.e., how much
you should be paid)
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Massive amounts of content needed
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Coding rules very complicated in E&M guidelines
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Defaults for normal examinations are faster than dictating,
however normal defaults have to be used cautiously..
◦ Large templates
◦ 1995 Guidelines nebulous
◦ 1997 Guidelines very specific and specialty appropriate – Used by
most EHRs
◦ Ideal for computational assistance
◦ Frequently cited reason why providers purchase an EHR, i.e., to
code visits more accurately
◦ E.g., normal lower extremities documented in a patient who has a
leg amputation
 The government is watching….
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Pulling forward a prior examination can be very efficient,
but needs to be done with caution
◦ Providers need to review each character on the screen and take
ownership
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Often placed in the clinical record between
physical and assessment
◦ May be in other locations such as the HPI,
assessment or plan
◦ Includes:
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Lab values obtained prior to or during the visit
Radiology findings obtained prior to or during the visit
Other test results (e.g., exercise treadmill test)
Reports from other providers
Procedures performed as part of the encounter
 E.g., draining fluid from a knee
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What is the provider thinking?
◦ Quickly assemble all relevant information to help
with making the diagnosis and treatment plan
◦ Don’t miss something relevant that would be
considered part of the standard of care
◦ Capture the fact that the information was reviewed
for reimbursement (E&M) purposes
◦ Enter the information efficiently
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EHR may or may not have ability to import lab
and other information of this nature into H&P
note
◦ For example, a PACS system may allow import of
radiology results)
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Often will not have ability to capture this as
information relevant to E&M coding
◦ Point system is used when providers look at test results,
look at actual images, etc.
◦ Need to be documented but can influence level of
complexity of visit
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May not have ability to template the procedure,
which are the most straightforward types of
encounters to document in EHRs
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Provider pulls together all relevant
information and often creates a “differential
diagnosis”
Differential diagnosis is a weighted list of
potential diagnoses
◦ Ranked based on
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Potential urgency
Can the problem be treated
What is the most likely underlying disease
What else needs to be considered?
 “Zebras”
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What is the provider thinking?
◦ Demonstrate that all relevant diagnoses, based on
clinical relevance, have been considered
◦ Demonstrate thought process behind conclusions
◦ Demonstrate level of knowledge to other providers
(in particular for specialists)
◦ Demonstrate that the patient has been made fully
informed regarding their condition
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Create tools that assist with diagnosis
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Clinical Decision Support (CDS)
List of alternative diagnoses to consider
Access to knowledge resources
Import diagnoses from other sections of the record
Modify diagnoses
Need to choose ICD-9/10 codes that are
needed for billing of the encounter
◦ Justify complexity of visit through description of
patient’s problem and potential risks to their future
health, and the risk of interventions
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Includes
◦ Diagnostic tests
◦ Treatments
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Medications
Surgeries
Therapy
Others
◦ Patient instructions
◦ Follow-up care
 Return visits
 Referrals to other providers
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What is the provider thinking?
◦ Prescribe medications where risk is offset by potential
benefit
 Fully inform patient of potential risks
◦ Order tests that confirm diagnosis or eliminate
diagnoses under consideration
◦ Refer patients as appropriate to other care provider such
as specialists
◦ Follow a plan of care that would be consistent with the
standard of care
 Patient education and counseling of particular importance
◦ Capture information that will be used for level of service
(E&M)
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Interact with data entered in other sections of
record to assist provider with management
◦ CDS (e.g., medication contraindications)
◦ Standards of care for specific conditions
 E.g., correct antibiotic to use
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Capture what was discussed with the patient
◦ Macros, templates, free text or VR often used
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Present provider with coding summary, including
level of service (E&M) coding assistance tools
Allow provider to close note and send relevant
information to a billing tool.
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Any questions?
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Contact information
◦ Email address: mcjstearns@gmail.com