Friday, January 8, 2010

Physician Business Ideas: For Practice Productivity, Why Not Let Patients Enter Data?

The question – why not? – is often behind practical innovations that led to increased practice productivity. As every physician knows, a time consuming and necessary aspect of practice is accurately entering patient data - age, gender, chief complaint, drugs being taken, allergies, review of systems, family history, past history, present history, chief complaint, and so forth.

This data is the basis for differential diagnosis and treatment, and for interviewing patients to get at the root of their problems. If symptoms are vague, the patient is uncertain or inarticulate, and the diagnosis is elusive, the process may eat up time and frustrate doctor and patient alike.

Over 15 years ago, Allen Wenner, MD, a family physician in Columbia, South Carolina, after missing a diagnosis of Sjogren’s syndrome because of not asking the right question, asked: “Why not develop software asking for all the right data and right questions for a given chief complaint in a patient of a given gender and age? He called his software The Instant Medical History (

His initial “why not” question led to these observations and other questions. What eats up time when you see a patient? Taking and documenting the history with a review of systems – correct? Moreover, third parties won’t pay unless you extensively document what took place.

The rest is history. Wenner formed a software company, Prime Time Medical Software, that has developed a series of clinical algorithms covering the diagnostic landscape and answering further “why not” questions.

More "Why Nots"

Why not let the computer take the history and record the review of systems from patients ? All of this could be done using simple “yes” or “no” algorithms based on the patient’s chief complaint, gender, and age. And it could be done by the patient in ten minutes or less from a home computer or a laptop in the reception room.

Why not let patients document why they are seeing the doctor? Why not let patients enter their own data, complaints, and histories using simple software, either from home or the reception room? Why not permit patients to tell their own stories on their own time, rather than the doctor’s time? Why not place a computer in the reception room to serve an ATM-like function, viz. enter the customers’ own data? After all, no one knows their history and their demographics and other data, including billing information, better than the patient.

For the last decade, Allen Wenner and John Bachman, head of primary care at Mayo in Rochester, have used the computer to gather patient histories with the Thousands of other doctors around the country are doing the same. The Instant Medical History is an integral part of many EMR systems, and any physician with broad band access can use the software.

Wenner and Bachman have gone on to ask. Why not let patients enter the exam room with their stories spelled out in a computer interview? Why not let them do it from their home computers? Why not program the history so that it appears as a narrative? Why not make it easy for physicians to simply add their findings with a few simple computer key strokes? Why not let patients leave the office with their documented histories and findings in hand? And why not let this comprehensive document serve multiple purposes – a medical record, a billing document, the source of referral letters?

What is the cost to physicians of patient-documented histories? Roughly $50 a month for software. The gain? Four to 8 minutes of time saved per patient. For a busy primary care doctor, this translate into 5 more patients each day. In addition, the instant medical history with accompanying doctor findings makes most dictation unnecessary, and the patient-generated record serves as a basis for claims initiation and enhanced coding. Further, the patient immediately has a clear record of what transpired, thereby minimizing confusion or misunderstandings that might lead to malpractice suits. Through impressive documentation , made possible through patient input, physicians can often appropriately code one level higher. Patients and third parties will be impressed physicians have moved up the electronic documentation curve by structuring the history and physical into a readable and comprehensive document.

1 comment:

Allen said...

Why not let the patients enter their own history? Patient entered data would empower the patient to communicate an agenda that was patient centered. In the doctor centric world, the patient can be cut off in 18 seconds during the medical interview.

Why not let the patients enter their own history? The patient would enter all the facts and outcomes could be measured because we would know where the patient started in the illness. The patient with expert software would have meticulously recorded codified data regarding the quality, context, duration, severity and timing of the illness. In addition, the patient would add modifying factors and associated symptoms - not a filtered subset from a hurried physician who is trying to treat the patient instead of recording data.

In the doctor-centric world the physician will naturally document a story that matches the diagnosis that is being considered. When the doctor enters all the data, then the same patient can go to three different doctors and three different medical records can result. Medical records are flawed by this bias. Our current medical record keeping is focused more on justifying the charge to a third party than it is to telling a story of the illness or communicating all the facts.

Let’s consider right upper quadrant pain in a healthy 45 year old. If the patient goes to a primary care provider, the clinician could rule out heart disease by a good history and presume dyspepsia. The patient might be given a $50 clinical trial and a blood test for H. pylori.

If the same patient went to a Cardiologist, the doctor would inquire if the pain ever came on with exertion. The patient who had not thought about it might be ambiguous or simply not know. This uncertainty would result in a series of expensive cardiological tests to rule out atypical angina. If, by chance, the patient had a normal variant on one of these tests, tens of thousands of dollars for more investigations would be spent.

If this same patient went to a general surgeon with the same right upper quadrant pain, the surgeon would inquire about pain at night or after eating. This might be unclear to the patient or it might have happened. Inevitably the patient would have an ultrasound of the gall bladder. We know that more gall stones are discovered at autopsy than at the surgical table, so if this patient has an incidental gall stone, an operation could occur.

Most interesting about all these scenarios is the patient’s medical record. These three medical charts will be totally different because they will reflect the doctor’s history, not all of what the patient said or thought. One could surmise that it would be quite difficult to ascertain outcomes with so much variation in the documentation. Outcomes can be studied only when the input is standardized.

Why not let the patients enter their own history? Allowing patients to enter data requires a total mind-set change by physicians. It demands a total commitment to quality, a respect for the patient, and a transparency in medical decision-making envisioned by the Institute of Medicine in the treatise “To Err Is Human.” Patient empowerment will evolve as doctors realize that the patient is the center of health care, not the health care system or the third party. In addition, patient entered data can complete the laborious task of filling in all the data required by an electronic medical record. Patient entered data will make the doctors job easier, support proper coding for third parties, and prevent malpractice from documentation errors or omissions. Finally, patient entered data makes paperwork a side-effect of the visit and allows the doctor to concentrate on the reason he/she went into medicine – to treat the patient.

DISCLOSURE: I am the lead designer of Instant Medical History ( I would strongly recommend the classic article “Patient Interview Software: A Tool that Can Help the Clinician” published in Mayo Clinic Proceedings, January 2003.

Allen R. Wenner, M.D.