Saturday, September 11, 2010

The Next Big Thing for Doctors – Lower Fees Mandated by Health Reform Law : The Next Big Clinical Innovation - Automated Patient-Entered Histories

Next: The Future Just Happened

Title of book by Michael Lewis, 2001

As a consultant to the Physician Foundation, a not-for-profit 501 C-3 Organization representing physicians in state medical societies, as a sometime futurist, and as someone who has written extensively about innovation in Innovation-Driven Health Care(Jones and Bartlett, 2007) and in 1475 blogs in Medinnovationblog, I have been asked: What is the next big thing for doctors, and how should they react to it?

The next big thing for physicians will be Medicare fee cuts in the neighborhood of 50% by 2020 as mandated by the Affordable Care Act, and the next big clinical innovative response for doctors will be encouraging patients enter their own data, their own chief complaint, and their own medical histories before seeing the doctor to compensate for fee reductions.

Ceding a Traditional Physician Function to Survive Economically

Doctors will have to cede a traditional function – taking a history – to patients to become more efficient to survive. Payers - including Medicare, Medicaid, and private health plans- will demand standardization and restructuring of the medical history to achieve consistency in medical records. Patient-entered information may be disruptive. Doctors will have to change practice flow patterns to adjust to reality of lower pay. The need for greater productivity will drive this change.

Patient- entered data, which is already happening, has positive aspects. It empowers patients by making them an integral and formal part of the diagnostic process. Patient-entered interviews, conducted by means of simple clinical “yes” or “no” algorithms, have these benefits – 4 to 8 minutes saved for each patient encounter, useful information for differential diagnosis, an increase of 5 or 6 more patients seen each day, the feeling by patients that they are partners in the diagnostic process, protection against misunderstandings leading to malpractice suits, greater coding revenues because of comprehensive documentation, and generation on the spot of a clinical document that can be used for referral letters, for claims processing, and for an electronic document that can be taken home by the patient on the day of the visit (see chapter 4, page 41, in Innovation-Driven Health Care).

Inevitable Trends

These trends make patients-entered data and histories is inevitable.

• Doctor and hospital fees will be systematically reduced to save Medicare, and structured electronic records will be required for payment. Reducing these fees is a fundamental part of the new health reform law as well as the government emphasis and financial incentives to install electronic records.

• Information technologies – i.e., the Internet, wireless devices, IPads, home computers, the social media, the whole electronic kit and caboodle – will make it practical for patients to automatically and seamlessly enter their data into doctors’ office computers.

• All doctors, primary care doctors and specialists alike, share in common an absolute need for a patient narrative history and certain data – identification numbers, chief complaint, age, sex, other demographics, family history, medications, allergies, symptoms, vital signs.

• The rest of society and other industrial sectors already have technologies in place that are making consumers do the work of obtaining or buying a service. These technologies lower the cost of doing business, replace the more expensive human interface, and make collection of revenues standardized, organized, systematic purposeful, and consistent.

• The underlying rationale behind all of these things are consistency and standardization, less hiring of fickle expensive human beings, and automation of business functions.

Look Around You

If you doubt what I am saying, look around you.

• Check into an airport, and a computer screen – without a human interface – will confront you.

• Check out at the supermarket, and you will have a choice of going through a clerk or a entering your selections on a computer.

• Call almost any business or government agency, and you will be marched through a voice-activated, computer-driven menu.

• Go to a bank for money, and you will likely get the cash through an ATM.

• Pay your bills and check your bank balance online.

• Prepare your annual tax return, and you will be more likely to do it through Turbo-Tax or its equivalent.

• Look for ways to lower legal fees, and you may well go to
Medical Practice Will Become Like Rest of World in Spite of Complexity

For the rest if the world, automated consumer entry information is an old story, but for medicine, because of the intensely personal nature of medical services, the need for privacy and fear of its loss, confidentiality issues, sacrifice of the human touch, resistance of physicians to traditional ways of doing things, i.e., taking the history face to face, automated patient entry is taking place at a slower pace, and the very complexity of the medical-social enterprise, assures a much slower pace.

Bob Wachter, MD, a West Coast academic and the moving force behind the hospitalist movement, explained the complexity well in a September 9 edition of The Health Care Blog, “With all due respect to the Pentagon, humankind has not invented a more complex organization than the modern academic medical center. The combination of high tech and high touch, the Byzantine regulations, the toxic medico-legal environment, the extraordinary pace of change…. Well, you get the idea.”

The medical environment may be even more complicated outside the academic medical center in the fragmented world of multiple specialists, different entry points into the system, and escalating health plans requirements for payment.

Complex or not, clinical innovation in the form of standardization and structuring of medical records, so that payments can be justified and outcomes tracked, is coming – and coming fast.

One need look no further than the health reform law and the federal government spending of $27 billion over the next ten years to subsidize, incentivize, and promote “meaningful” electronic health records. This starts in earnest in 2011.

Standardizing Care Delivery – The Next Big Thing

Standardizing delivery of care -- identifying “best practices,” and insisting physicians follow guidelines – theoretically could save money while improving quality. It is the basis for Obamacare. For government management experts, the allure of standardization, and the seductive comfort of quantitative metrics (however meaningless and off-target) and rigid guidelines (however unwieldy and irrelevant) is too powerful to resist.

In my opinion, the next big data trend in health care will be structured patient data entry during e-visits and meeting with the doctor in the exam room. These structured e-visits can be entered seamlessly into an office-based computer or into an electronic medical record.

Why Nots

Why not let the computer take the history and record the review of systems from patients? All of this can be done and is being done using simple “yes” or “no” algorithms based on the patient’s chief complaint, gender, and age (see And it can 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? 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. letting health consumers enter their own data? After all, no one knows their history and their demographic and other data better than the patient.

For the last decade and one half, Doctors Allen Wenner, a South Carolina family physician and John Bachman, head of primary care at Mayo in Rochester, working collaboratively have used the computer to gather patient histories using a software tool known as the Instant Medical History( Thousands of other doctors around the country have done so as well.(Bachman, J., The Patient-Computer Interview, Mayo Clinic Proceedings, 78, 67-78. 2004)

Wenner and Bachman ask. Why not let patients enter the exam room with their stories spelled out in a computer interview? 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?

Costs of Patient Information Entry

What is the cost of patient-documented histories? Roughly $50 a month for software. The gain? Four to 8 minutes of time saved per patient. In addition, it saves money by making most dictation unnecessary, and the patient-generated record generates even more revenue per patient encounter by consistently serving 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 comprehensive documentation , made possible through patient input, codes often up one level. Patients and third parties will be pleased doctors have moved up the electronic documentation curve by structuring the history and physical.


As with anything in this turbulent world of Sturm and Drang and rapid and accelerating change, the devil is in the details. For patients to enter information requires that physicians have a compatible computer system or electronic health record that will accept the data. It requires physicians and patients have comfort, confidence, and competence with computers. It requires that patient privacy be protected and sensitive parts of the record be kept confidential. It requires acceptance of the brave new world the Internet has created. It requires acceptance of the naive idea that for every complex problem, there is a simple solution. It requires flexibility, viz, rejection of the thought that patient-entered data will apply to all patient visits - follow-ups, prescription refills, phone and e-mail enquiries.


The two next big things for physicians will be systematic reduction of fees proposed by the new health reform law , The Affordable Care Act, and the need for some sort of systematic response resulting in lower costs of practicing through greater practice efficiency and productivity. One such response may be structured patient-entry of their own data and history using clinical algorithms . History taking and data entry now requires significant physician and physician staff time and may be inconsistentwith resultant claims rejections with delays in payment.


Anonymous said...

I don't doubt payments will fall to reflect the expected saved time, but the only time the doctor will save is the dictation of the history (if docs are allowed to skip this part). I have tried a structured patient data entry in my pain practice, which has a limited scope compared to primary care. Patients are disorganized (so the doc has to take time to make sense of the history), they answer questions wrong (leading to time consuming backtracking), they don't know or skip a lot of their history (more interview time), and some just refuse to do the data entry.

In my opinion the best computer patient interviews will do is comparable to a bright medical student, i.e., plowing through every possible question and applicable branch of questioning. Remember how long it took during medical school? At least an hour for a history. Experienced docs short-cut the process through expertise and observation of the patient during the interview.

The way the system is operating now, my prediction is that patients will be forced to spend a lot of time going through the data entry, which will generate lots of 'paper' and documentation, but will do little to improve the efficiency of clinicians.

Richard L. Reece, MD said...

You may be right, but if the clinical algothims are restricted to "yes" or "no" answers, there isn't much room for patient equivocation.