News 8/12/14

Top News

HHS works to reconstruct CMS Administrator Marilyn Tavenner’s email inbox in response to requests for missing emails sought by congressional investigators relating to the flawed rollout of Healthcare.gov. The recordkeeping problem was discovered as HHS officials collected documents in response to subpoenas from Republican Rep. Darrell Issa of California, who chairs the House Oversight Committee. HHS expects to recover “most but not all” of the 10,000-12,000 emails Tavenner receives each month. The department has expended over 23,000 staff hours and turned over 135,000 pages of documents in response to the subpoenas. It does my pocketbook good to know my tax dollars are being put to such thorough use.

Acquisitions, Funding, Business, and Stock

United Food and Commercial Workers, Local 293 and meat company JBS USA announce plans to open an off-site medical practice run by an outside contractor for 5,000 employees and family members covered by the self-insured company’s health policy. The company is now evaluating candidates, hospital networks, and boutique clinic providers to operate the Nebraska practice, which will be run as a patient-centered medical home.

CVS Caremark Corp. opens its first walk-in MinuteClinics at select CVS stores across the states of Nebraska and Washington. The company now has clinics in 30 states and Washington, D.C., making it the largest and fastest expanding provider of such retail clinics in the U.S.

This blog highlights the growing threat of patent trolls, particularly to those companies working in EHR software development. “It’s a rapidly growing segment of the healthcare industry that is almost entirely software-based,” notes lawyer Leland Schultz, “and the leading companies don’t appear to be paying sufficient attention to patents, either as a valuable business asset or as a threat to their business.”

DrFirst secures $10 million in debt financing, which it will use to expand its development resources and prepare for international expansion.

Medicity and athenahealth will improve interoperability between their systems.

Announcements and Implementations

Infinity Primary Care (MI) selects population health management and analytics solutions from i2i Systems to help it easily produce reports associated with its quality measures and Meaningful Use participation. The majority of its 12 physician practices serving West Detroit are recognized as patient-centered medical homes.

The California Public Employees Retirement System (CalPERS) launches an online healthcare comparison tool for public-sector workers insured by Anthem Blue Cross. Developed by Castlight Health, the tool enables plan members to compare physicians, hospitals, medical tests, and procedures on a variety of factors including cost, quality, patient satisfaction, and convenience. Users can also track expenses.

Government and Politics

The White House creates the US Digital Service, a new program that will recruit the “country’s brightest digital talent” to provide strategic guidance on major IT projects like Healthcare.gov and iEHR. Mikey Dickerson, the engineer credited with saving Healthcare.gov, has been tapped to run the service. If his LinkedIn profile is any indication (No Fancy Title, Thanks), he’s likely to keep a low profile while getting the job(s) done.

The state of California’s Department of Health and Human Services launches a health portal to display high-value data sets to residents and developers. Initial data sets include popular birth names, birth profiles, poverty rates, locations of vendors that accept vouchers from government assistance programs, a mapped timeline of West Nile virus incidents, asthma statistics, and healthcare facilities data. Future data sets are likely to include healthcare construction and financing, workforce, and data comparing healthcare costs with quality of care.

ONC launches a website designed to collect feedback on its proposed interoperability roadmap. Stakeholders have until September 12 to provide their thoughts and comments, after which ONC will present aggregated feedback to the Federal Advisory Committee for its input and recommendations. An updated version of the roadmap will be posted for public comment early next year.

Research and Innovation

A survey finds that telemedicine could potentially deliver over $6 billion a year in healthcare savings to companies in the U.S. thanks to an expected 68-percent increase in the use of telemedicine services by employers. According to survey findings, 37 percent of employers expect by 2015 to offer employees telemedicine consultations as low-cost alternatives to ER or physician office visits for non-emergency health issues. Another 34 percent are considering offering telemedicine services in 2016 or 2017.

This blog highlights the growing interest in personal health data research and the challenges that set it apart from traditional health research, which is typically controlled, specific, and very focused. Personal health data research involves real-time data that is highly variable and without experimental controls or organized sampling. It is also prone to self-selection thanks to the rise in consumer use of smart phones and wearables. “Analyzing this type of ‘big data’ will require new statistical approaches, drawing from the fields of computer science, atmospheric science, and engineering,” explains Kevin Patrick, principal investigator for the Health Data Exploration project.

People

Shelly Russell is promoted to CEO of Mitchell County Regional Health Center (IA).

Harrison Fox (Continuum Care Improvement Through Information New York) joins the Lantana Consulting Group as product manager/project manager.

Other

IBM, Cornell Tech, and iniLabs continue to make progress on the SyNAPSE chip (Systems of Neuromorphic Adaptive Plastic Scalable Electronics), which emulates the human brain by processing extreme amounts of sensory information with very little power. After two years in development, the chip is now capable of 1 million programmable neurons, 256 million programmable synapses, and 46 billion synaptic operations per second, per watt. Potential applications include assistive glasses that could guide a visually impaired wearer without need of a Wi-Fi connection, and solar-powered, leaf-shaped sensor modules that could send out environmental and forest fire alerts.

St. Lawrence Medical Practice (U.K.) attempts to ban patients from posting negative comments about the practice on social media. The request was made after staff allegedly saw bad language used to describe the surgery’s standard of care on Facebook. Foul language aside, telling patients they’re not allowed to post negative comments on the social network of their choosing will ultimately backfire. Case in point: the New York hotel that attempted to “fine” brides $500 for every negative review left by their guests on any social network. The result: a slew of one-star reviews and comments on the hotel’s “terrible service” and use of intimidation.

HIPAA worries are causing obstetricians to remove “baby boards” that feature photos of babies they’ve delivered from their office walls. An OCR representative confirms that the practice is illegal even if the family sends the picture for that purpose since “implied consent” doesn’t count.

A new regulation in India requires doctors to write prescriptions in all capital letters to avoid sloppy cursive handwriting that was causing medication errors.

Sponsor Updates

• PerfectServe posts an article titled “The Changing Role of the Physician.”
• Allscripts is named among the best EHR vendors according to Black Book rankings data.
• ADP AdvancedMD spotlights three smaller private practices using its cloud solution to stay clinically and fiscally efficient.
• Kareo suggests six steps to take in hiring the right staff for a medical practice.
• NextGen Healthcare announces a new name for its November user group meeting, NextGen One.
• SRSsoft will participate in the American Society for Surgery of the Hand conference September 18-20 in Boston.
• Allscripts shares what “Open” means for healthcare and why it’s so important.

Contacts

Mr. H, Lorre, Jennifer, Dr. Jayne, Dr. Gregg, Lt. Dan, Dr. Travis

More news: HIStalk, HIStalk Connect.

Get HIStalk Practice  updates.
Contact us online.

DOCtalk with Dr. Gregg 8/11/14

HIT Leads to HID

What’s that you say? What’s HID? Oh, sorry. That’s a new acronym going around related to the semi-rapidly-changing world of HIT.

HID stands for Health Information Disappointment.

If you’re anything like me, that definition rings both a cord of immediate understanding as well as a bell of bittersweet irony. If you’re a user of HIT to document, derive, or disperse health information, it is almost a guarantee that you intimately know the aches, pains, and disappointment involved.

Despite any (all?) HIT vendor’s best promise to the contrary, documenting digitally can be exasperating. The difficulty of completing virtually any digital documentation of a healthcare task is often harder than performing the task itself. (OK, so maybe certain procedures like quadruple coronary bypasses or triple organ transplants are harder than the documentation thereof, but the comment stands for many of medicine’s more commonplace care tasks.) Some systems do the documentation dance with more fluidity than others, to be sure. However, for many (most?) providers out there, recording their necessary daily data to adequately comply with all requirements – be they reimbursement or incentive – has become decidedly dreary, dull, and a drain upon their day.

(While writing this piece, Dr. Andy Spooner posted a very insightful “rant” entitled Scout’s Honor that highlights one very significant facet of this documentation dilemma. A good read.)

As disappointing as the recording of computerized health information can be, it isn’t nearly as disheartening as trying to derive information from another’s digital documentation – especially if it comes from a system outside your own, and even more so if it’s a printout version thereof. (So few systems actually share digitized data into reciprocally relevant information buckets that the conversation at this point is pretty much limited to printout information sharing, be it faxed or snail mailed.)

Digitized data entry has certainly eliminated the human eye-brain handwriting recognition and interpretation problem from the mix. However, it seems to have replaced that form of crypticism with one that, while legible, is often barely readable. Too long. Too short. Too poorly designed from a readability perspective. Too filled with reimbursement- or incentive-related gibberish that adds nothing of any identifiable value to the clinical narrative. If you’re a provider, you’ve seen each of these and you know how difficult it can be to divine the necessary clinical pearls of relevance from the splattershot of documentation detritus.

As to the distribution of healthcare information, well, that’s pretty much the reason fax machines are still being manufactured. We haven’t made too many advances for health data dispersal since the first commercialized version of the fax machine hit the markets in the mid-60s. (Sort of sad, when you think about it.) Sure, we’re starting to build connectivity and signs of sharing are certainly sprouting up here and there. Yet, the reality for most of us, most of the time, is that we’re still quite some distance from a system that shares data more effectively than our faithful old fax machines.

With healthcare’s current state of digitized over- or under-documentation, with medical storytelling that while legible is still cryptic, and with the ongoing limitations of health information sharing, is it any wonder that we have Health Information Disappointment?

From the trenches…

“I’m disappointed, but I’m not going to run around like Dennis Rodman and head-butt somebody.” – Greg Norman

(“Well … not yet.” – Dr. Gregg)

Dr. Gregg Alexander, a grunt in the trenches pediatrician at Madison Pediatrics, is Chief Medical Officer for Health Nuts Media, an HIT and marketing consultant, and sits on the board of directors of the Ohio Health Information Partnership (OHIP).

Contacts

Mr. H, Lorre, Jennifer, Dr. Jayne, Dr. Gregg, Lt. Dan, Dr. Travis

More news: HIStalk, HIStalk Connect.

Get HIStalk Practice  updates.
Contact us online.

5 Questions with Mark Gettleman, MD Founder of Goofy Gettwell Pediatrics

Mark Gettleman, MD is the founder of Goofy Gettwell Pediatrics, an independent practice that recently opened in Scottsdale, Arizona. He offers house calls via the GoGo Gettwell mobile, as well as phone, video, and e-mail consultations. Patients can also take advantage of Gettleman’s proprietary, online Electronic-Rash Identification service, which enables parents to securely send images of ailments to Gettleman for consult. Gettleman considers the practice to be a startup business, one with very little overhead thanks to relationships with vendors like PayPal and other HIPAA-compliant business associates. He does not accept insurance and is not participating in the Meaningful Use incentive program. His mobile practice typically sees six to eight patients a day, while his bandwidth for video, phone, E-RID, and e-mail consultations has yet to be reached, though he notes the upcoming cold and flu season may alter that. 

You started Goofy Gettwell Pediatrics after spending 18 years at a brick and mortar practice. What led you to move from that type of business to this one? Was there a final straw that prompted you to make the switch?
I came out of medical school as far from the typical, idealistic, wide-eyed newbie doctor as you could be. I had no ambitions to change the world or cure cancer. I just wanted to do my thing in my small corner. After working for someone for three years, my frustrations with his management style led me to start my own practice. I was managing partner of a thriving, economically successful practice for 15 years.  But, I was becoming more and more despondent over the medical system. I hated this triangular model where the provider, the patient, and the payer are all pulling for different purposes. The patient, without knowing it, had given the power of the purse away and was left with little influence. 

Then I read the ACA (Obamacare) and I realized how bad the system was going to get. The cost-containment feature would be entirely up to the secretary of health and human services, and implemented as metrics and bundling through the government and accountable care organizations. I realized that Washington was now going to control what I was allowed to do in the exam room. 

Under the ACA law, well visits (preventive medicine) are fully covered, or free to patients. The natural repercussion of this was an increase in sick visits not being covered until deductibles were met.  This new model sent shockwaves through our billing department, and unsuspecting patients become irate and hysterical when we tried to collect.  It was a nightmare. 

In addition, issues that the government didn’t deem preventive were not allowed to be discussed.  If a question about asthma or allergies came up in a well check, I was obligated to code the visit accordingly, which kicked it out of the preventive category. Hundreds of dollars of immunizations would then no longer be covered and patients were forced to pay these huge fees, or I was left to cover the costs.  Some practices were audited, charged with fraud, and forced to pay huge fines for not following the guidelines.

The last straw had to do with the metrics. The public “rating” of the physician, which is tied to the reimbursement, had to do with fulfilling a few dozen criteria, from doing certain tests to patient survey results.  While most were reasonable, many should be directed by the situation. For example, one metric insists that I discuss and screen for STDs like chlamydia with all patients 13-years old and above. While this is appropriate for many of my patients, some are prepubescent, immature, and still playing with their Barbies. I would not dream of venturing into a discussion about STD and therefore sex until a parent and I had decided the timing was right. 

Would you consider your business model to be concierge? Has healthcare IT better enabled you to operate in this fashion?
I’m not sure about the monikers. Concierge, direct primary care, fee for service, private physician …  I just took a step back, thought about what patients would like and what I could do for them.  I can not charge a lot, because in pediatrics people are young and just starting to build wealth. I can keep my overhead very low by offering home visits, but I can only see a limited number of people per day. The IT component allows me to see more patients and help greater numbers of kids more quickly and efficiently.

How have your patients reacted to this type of business model? What do they appreciate most about the technologies you offer?
They have LOVED it – mostly the convenience of not having to leave their homes.  I’ve treated kids on Easter; via e-mails; and with photos from a smart phone, which saved long waits in the ED. I saw a three-day old who was feeding poorly and was able to alleviate the tremendous fears of the parents on a Saturday morning.  I did a video visit with one mom during which we discussed issues related to autism and behavior without needing to upset the child with the new and strenuous stimuli of an office visit. These parents are thrilled with the service.

How do you foresee your practice adapting to the wants and needs of an increasingly savvy patient/parent population, especially considering the speed at which digital health is bringing healthcare onto phones and tablets and into the home?
Many of my patients are still leery about using IT. We need to walk a few through the steps. As patients get used to it, they love the system. I envision extending to many more programs as technology becomes both more accepted and affordable. The thought of using heart, lung or blood pressure monitors over a smart phone, or using a picture of the tympanic membrane to diagnose an Otitis Media excites me.

What best practices or advice can you offer physicians looking to take their practices to the next level of healthcare IT?
Don’t be afraid. There are tons of reasons to not to do things, but when push comes to shove, it is up to you.  If you, as the physician, lead the way, the patients who trust you will come along. As Steve Jobs once said, “People don’t know what they want until you show it to them.”

Contacts

Mr. H, Lorre, Jennifer, Dr. Jayne, Dr. Gregg, Lt. Dan, Dr. Travis

More news: HIStalk, HIStalk Connect.

Get HIStalk Practice  updates.
Contact us online.

News 8/7/14

Top News

Cerner validates rumors that have been swirling for weeks when it announces it will acquire the assets of Siemens Health Services for $1.3 billion in cash. Cerner Chairman and CEO Neal Patterson told HIStalk that “the broad driver is the post-Meaningful Use era” and the large R&D budgets of both companies. The combined organizations will have 20,000 employees, 18,000 client facilities, and $4.5 billion in annual revenue. Two Cerner executives will join the Siemens leadership team. Only the client experience and administrative functions will be combined in the short term. Cerner expects the transaction to close in Q1 2015.

Acquisitions, Funding, Business, and Stock

Practice Fusion acquires Ringadoc in a timely move into the telemedicine market. Ringadoc provides after-hours answering services to 1,000 physicians, some of which are already Practice Fusion clients, and has been testing a service that allows patients to consult their doctors over the phone for $40. The acquisition formally solidifies the already close relationship the two companies have had for some time. Practice Fusion CEO Ryan Howard is an investor in Ringadoc, which was previously based in Practice Fusion’s San Francisco offices.

Telehealth and medical billing services company GoTelecare introduces a franchising business that will enable physicians and healthcare facilities to provide video consultation services using its online platform. As I mentioned in my musings on the future of telemedicine earlier this week, the industry is likely to see a flood of related technologies (and new business models) pop up in the next several months as reimbursement is optimized and state licensing issues become less of a barrier for physicians.

Core Sound Imaging Inc. joins athenahealth’s More Disruption Please program, through which it will offer athenahealth customers its Studycast cloud PACS software.

MModal exits Chapter 11 bankruptcy following financial restructuring and debt reduction of 55 percent. It too joins the athenahealth More Disruption Please program, offering Fluency Direct and Fluency Flex mobile solutions via the MDP marketplace.

Futura Mobility expands its healthcare division through a partnership with Practice Unite. The two-year collaborative arrangement will enable Futura to integrate Practice Unite’s HIPAA-compliant messaging app with its IT services. Physicians can use the app to send 256-bit encrypted text messages, search for specialists, facilitate outpatient procedure requests, conduct physician surveys, and send emergency alerts.

Government and Politics

CMS temporarily suspends use of its Open Payments system that shows payments made to doctors by drug and medical device companies. CMS found that a batch of payment records from an unnamed company had assigned payments to the wrong doctor by including an incorrect state medical license number. The temporary shut down likely fueled the fire of over 100 medical professional groups that collectively sent a letter to CMS asking it delay launch of the system, which is expected to go live September 30. The letter-writers note that, “There are widespread concerns that the implementation of this new system for data collection — without minimally a six-month period to upload the data, process registrations, generate aggregated individualized reports, and manage the dispute communications and updates — will not be ready and will likely lead to the release of inaccurate, misleading, and false information.”

ONC announces it will hold its 4th Annual Consumer Health IT Summit in Washington, D.C. on September 15. The event will feature an update on the Blue Button Initiative, "bright spots" that demonstrate what digital health data and technology can do, discussions about ways to engage underserved populations and to improve patient participation in clinical trials, and dialogue about frontier areas such as personalized medicine and patient-generated health data and how they can help to improve health.

In other ONC news, it announces chairs and co-chairs for the recently realigned HIT Policy Committee Workgroups.

The HIT Policy Committee provides an update at its recent meeting on the timing of its 10-year interoperability roadmap, outlining three-, six-, and 10-year milestones. A draft of the roadmap is expected to be published in October. A second version including feedback from ONC’s health IT policy and standards committees will likely be available for public comment by January 2015, while the first formal version of the roadmap will be released in March 2015. The committee also covered the latest numbers for Meaningful Use: As of August 1, close to 1,900 physicians and other eligible professionals have attested to Stage 2.  Nearly 90 percent of physicians and other EPs have registered to participate in the EHR incentive payment program; 75 percent of those have received at least one incentive payment. The physician participation numbers look good on paper, but it seems like Stage 2 requirements are giving providers a run for their money (likely already spent on EHR implementations, upgrades or replacements).

Announcements and Implementations

Radiology practice Omnirad (MI) announces a billing partnership with radiology billing and practice management service provider Zotec Partners.

Premier Medical PC (AL) selects revenue cycle management services from McKesson Business Performance Services. The group, which provides emergency services to a nearby hospital and urgent care center, will move from internal billing to McKesson’s coding, billing, claims submission, A/R management, business intelligence reporting, regulatory compliance, physician documentation education, PQRS compliance, and managed care negotiations assistance services.

California Integrated Data Exchange, funded by $80 million from Blue Shield of California and Anthem Blue Cross, announces plans to develop the Cal Index statewide HIE. Cal Index says it will go live in late 2014 with 9 million records online. Initial funding covers the first three years of operating expenses, after which the HIE plans to sell subscriptions.

Research and Innovation

Screening for Mental Health Inc. and the Philadelphia Department of Behavioral Health and Intellectual disAbility Services unveil their behavioral health screening kiosk at a QCare retail health clinic. The kiosk was the winning entry in a contest that challenged contestants to create a way to make mental healthcare education or access available at retail clinics. The assessment tool — thought to be the first in a retail-clinic setting in the U.S. — offers people quick, free, and anonymous behavioral health screenings (“a check up from the neck up”) via mounted tablets in the clinic’s waiting area. The idea is a good one, but if the picture above is any indication, I fear that anyone who wonders if they suffer from mental health issues will be turned off from using the kiosk by the lack of privacy around it.

The American Heart Association launches an Open Innovation Challenge on Medstartr for Midwestern startups with ideas about how to help people prevent or manage cardiovascular disease or stroke. The 10 best ideas move on to a crowdfunding competition, and the top three then pitch to judges and investors in Chicago. The winner gets a $20,000 grant and whatever crowdfunding money they raise. Applications are due September 12.

A study of 51 primary care practices within the Colorado Beacon Consortium finds that they value support and resources that assist them with using healthcare IT, including:

• Translating rules and regulations into individual practice settings.
• Facilitating peer-to-peer connections.
• Providing processes and tools for practice improvement.
• Maintaining accountability and momentum.
• Providing local EHR technical expertise.

Benefits of support included improved quality measures, operational improvements, increased provider and staff engagement, and deeper understanding of EHR data.

People

The Michigan Academy of Family Physicians elects Pierre Morris, MD vice president. Morris is director of the Wayne State University Family Medicine Residency Program.

Nonprofit community health organization Sun Health promotes Jennifer Drago to executive vice president of population health.

Stephen Kahane, MD (athenahealth) and Rick Jelinek (Advent International) join the RedBrick Health Board of Directors.

Other

Forbes highlights the physician entrepreneur phenomenon, citing Aledade founder Farzad Mostashari, MD, and Iora Health founder Rushika Fernandopulle, MD as two of a growing number of physicians that have moved from clinical practice to startup business, often with a stop-off in government or nonprofit work in between. Fernandopulle explains his transition as one prompted by frustration: “I decided that the best way to make change happen quickly was to simply strike out myself and just do it – being an entrepreneur allows you to break what others think are the rules (they aren’t) and take change into your own hands.”

A new paper from the Center for Innovation Technology at Brookings outlines six recommendations to help healthcare progress in the areas of interoperability, privacy, and security:

• Use big data tools.
• Increase interoperability and tracking patients across healthcare systems.
• Increase patient education (and improve user experience).
• Implement a diverse set of patient records with online patient access.
• Ensure privacy.
• Recognize the reality of third-party consultations.

Minnesota ranks first when it comes to healthcare ROI, according to a study that reviewed each state’s death rates, health rankings, and insurance premiums. Utah, Kansas, Hawaii, and Iowa round out the top five, while Mississippi, Louisiana, Arkansas, West Virginia, and Indiana achieve the ominous distinction of being at the bottom.

The Population Health Alliance seeks nominations from within its membership for its Board of Directors. Final approval of nominations will be given at the PHA Forum 2014 in December.

Sponsor Updates

• Greenway extends special pricing for Engage14 in Dallas, September 4-7.
• Greenway suggests how to select the clinical quality measures for a primary care practice.
• Allscripts announces speaker information and the agenda for ACE 2014 in Chicago, August 12-15.

Contacts

Mr. H, Lorre, Jennifer, Dr. Jayne, Dr. Gregg, Lt. Dan, Dr. Travis

More news: HIStalk, HIStalk Connect

Get HIStalk Practice updates.
Contact us online.

CMIO Rant With … Dr. Andy

Scout’s Honor
By Andy Spooner, MD

“A 10-system Review of Systems was performed and found to be noncontributory.”

Billing compliance auditors get queasy when I put the above language in an electronic note.

Should they? I really did do a review of systems!

Scout’s honor!

The documentation quoted above is not by itself non-compliant. The passive voice is used skillfully in the E & M coding rules to describe the complete review of systems:

“At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible.”

–1997 Documentation Guidelines
for Evaluation and Management Services
U.S. Center for Medicare and Medicaid Services

If you had — in your head — reviewed 10 organ systems during your history, then the above “noncontributory” statement would be compliant. So why the queasiness?

It’s worrisome because it seems like one of those “easier said than done” situations. It’s easy to insert a line of text that describes a complex thought process. But did you really think of all 10 organ systems? The solution to the queasiness is to call for a list of exactly everything you asked the patient about.

Why should we care how many organ systems someone thought about?

We have obligated ourselves (via the E & M guidelines to which we all subscribe in the U.S.) to show that we thought about multiple organ systems in the case of complex patients — if we want to get paid for complex care. There is nothing wrong with this concept, but then we have the problem of how to show that we performed this thinking. The most common way to indicate review-of-symptoms thinking — the method that seems safest to the compliance auditors — is the symptom checklist, where we enumerate everything the patient doesn’t have.

The irony of the checklist solution (there’s always irony when it comes to compliance) is that it tends to transform a valuable thought process (a physician’s internal review of his or her total knowledge of human pathophysiology) into a litany of irrelevant information that we care very little about. We see that performing this checklist process as being beneath us. We begin to care so little about “doing a review of systems” that we gladly detach this process from the act of history taking. We isolate it in several ways:

• We make it a separate part of the chart, as if reviewing systems can be performed independently of taking a history. It can be done separately, but why bother? Thoughtful coding consultants will tell you that the review of systems does not have to be a separate section, but even if it is embedded into the HPI, it still needs to be in some form where one can count “bullets” to assign to the canonical list of organs.
• We delegate this task (via the E & M guidelines) to absolutely anyone else who wants to “do” a review of systems. That’s not to say that a checklist produced by a medical student or nurse or a medical assistant isn’t accurate. The information is usually just fine. But unless it is integrated logically with the history of what is going on, what use is it?
• We gladly accept a patient-completed questionnaire for the information-gathering task. There’s nothing wrong with patient input, but if “doing” a review of systems is supposed to reflect the doctor’s thought process, how does a patient questionnaire do that?
• We work to ignore this separate blob of information. A study published recently by Clarke et al. on the information needs of ambulatory physicians suggests that the review of systems is usually regarded as superfluous — part of the noise. I get feedback from referring physicians that the thing they would most like omitted from letters sent to them by consultants is the review of systems (followed quickly by the past/family/social history and physical exam).

Some medical students buy laminated cards that spell out a review of systems in the form of a giant checklist. The result is what you’d expect:

ENDOCRINE: No blood sugar problems, cold intolerance, growth excess, heat intolerance, abnormal hair growth, impotence, increased thirst, increased appetite, frequent urination, skin discoloration, sweating, excess thirst, increased urination, or weakness

I always love to see that in the chart of a four-month old with bronchiolitis.

What’s going on here? Is it a bad idea to review a patient’s systems? Of course not. The goal is to make sure that we think of disease processes that fall outside our preconceived notions of what the patient has. Since all that wheezes is not asthma, the skilled clinician wants to be sure not to miss one of those unusual causes like a bronchial foreign body, vocal cord dysfunction, or cystic fibrosis. So why can’t the skilled clinician simply say that? We could even have the computer generate a differential based on documented findings, and then we could simply check a box that says something like “yes, I considered all of that.” (Or “yes, I considered all of that, and did not bewilder my patient by asking about cold intolerance or how many pillows he sleeps on because that’s just not relevant here.”)

E & M coding rules are based on the assumption that we are using paper, and that every additional bit of information we record costs us a little bit of energy. The argument goes that if we want to get paid more, we will be more willing to spend the energy to fill the paper with information in proportion to the complexity of the patient’s situation. With electronic systems, this calculus of documentation energy no longer applies. We can create long documents with very little energy. Since the paper-based rules assume a symptom checklist (paper is great for checklists), that’s what we make our electronic systems create for us. The subsequent “review of systems” is almost always meaningless.

If our purpose on reviewing systems is to assure that we consider broad possibilities in the diagnostic evaluation of the patient, why can’t our computer systems help us with that directly? We might be able to design our EHRs to be more useful if we could just let go of the assumption that the unit of analysis is the document, rendered as if on paper.

Ultimately, the rules about how to document are based on skepticism — perhaps a healthy skepticism — that we are going to do the intellectual work required to deal with complex clinical situations. This skepticism is here to stay, but the model of responding to it with bizarre lists of symptoms does not have to. Our clinical systems are capable of recording our efforts at creating a differential diagnosis. That intellectual work should count.

Scout’s honor!

Andy Spooner, MD, MS, FAAP is CMIO at Cincinnati Children’s Hospital Medical Center. A general pediatrician, he practices hospital medicine when he’s not enjoying the work involved in keeping the integrated electronic health record system useful for the pediatric specialists, primary care providers, and other child health professionals in Cincy.

Contacts

Mr. H, Lorre, Jennifer, Dr. Jayne, Dr. Gregg, Lt. Dan, Dr. Travis

More news: HIStalk, HIStalk Connect.

Get HIStalk Practice updates.
Contact us online.