The Tech Doctor: Self-Service Medicine?

From gas station fill-ups to airport check-ins, we are rapidly becoming a self-service society. Is there a way this trend might benefit docs in ambulatory practice?

Yes. It’s called patient-entered histories.

Here’s the basic idea behind this brand of self-service medicine: A patient fills out an interactive computer questionnaire prior to a visit. Her responses are automatically transferred to her electronic chart. That way, when the physician sees the patient, he is reviewing the patient’s questionnaire and can focus on the objective, assessment, and plan part of the visit.

Proponents of patient-entered histories claim the following benefits:

• Better information. A review article in Mayo Clinic Proceedings on this topic noted that in traditional physician-patient interviews, 50 percent of psychiatric problems are missed, roughly 50 percent of patient problems and/or concerns go unaddressed, and patient and physician do not agree on the primary complaint 50 percent of the time.

Since computer-based patient-entered histories work by using structured Q & A or a checklist type of approach, they offer a more consistent, standardized method of information gathering. Computer-based questionnaires also tend to excel at collecting sensitive information that patients may not feel comfortable verbalizing in a face-to-face encounter.

• Less work for providers. Whether you are writing a note, using dictation, or typing into an EMR, documenting the subjective part of the note can be time consuming. Why not have patients tell (i.e., document) their own stories?

• Better patient visits. Patient-entered histories lead to a more efficient and rewarding encounter since providers can focus on reviewing the information with patients instead of collecting it.

• Improved coding. Coding levels are directly correlated to the documentation of what you see and do. Therefore, since patient-entered histories make it easier to document the subjective portion of the visit, it is easier to play by the documentation rules.

This all sounds good on paper. But does it work in the real world?

To answer this, I found a small, primary-care practice that had integrated patient-entered histories into its daily routine. Here are my questions and their responses:

• How and where do patients enter the data? As part of the phone registration process, patients receive a password, and they are then instructed to go the practice’s Web site to fill out the questionnaire. The questionnaire uses “branching logic,” which means that the line of questioning is based on responses to previous questions. This means that the questionnaires are essentially customized for each patient based on his specific condition. After completion, the results of the questionnaire are summarized and securely sent to the practice’s EMR.

• What about patients who hate computers and/or do not have Web access? The MA will walk through the computer questionnaire in the exam room with these patients (who are often elderly), interviewing the patients, and answering questions on their behalf.

• How long does it take patients to fill out the questionnaire? A complete physical takes the longest - up to 15 minutes. More focused visits take about 3 minutes for the patient to fill out the survey.

• How do patients like it? With the exception of a relatively few patients who are computer phobic, there have been no major complaints. Virtually all patients fill it out, and most do it on their own. The practice also reports that the Web-based questionnaire is intuitive, requiring minimal support for help.

• Has it helped your coding? Yes. Unfortunately, the practice did not share specific stats.

OK, that sounds pretty good. So what are the important caveats?

Like most innovations, there are costs and work flow changes required to make it fly. You will need a Web site, a subscription to a company that creates the patient questionnaires, and an EMR. I suppose a paper-based practice with a Web site or patient kiosks could use this tool too, but doing so will add the task of getting the completed questionnaires into the charts - an unwieldy proposition that nearly negates the work flow benefits of patient-entered histories. You’ll also need to take some time training your reception and clinical staff to direct patients to the Web site prior to appointments.

Of course, not everyone is going to like talking to the computer prior to a visit, so you will have to put processes in place to manage exceptions (such as using the MA to walk the patient through the interview, as described above).

Finally, note that while the patient-entered history is a time-saver and offers a more standardized approach to patient interviews, it is no replacement for clinicians. Computers are terrible at picking up nonverbal cues, and patients tend to over-report on questionnaires, leading to a higher false positive rate.

However, in an increasingly online era, patient-entered histories do offer the promise of nicely combining good medicine for patients and improved productivity for the practice.

Bruce Kleaveland is president of Kleaveland Consulting, a management consulting firm focused on healthcare IT. Prior to forming Kleaveland Consulting, he was chief operating officer at a leading EMR company. He can be reached via editor@physicianspractice.com.

This article originally appeared in the July/August 2008 issue of Physicians Practice.