ORIGINAL CONTRIBUTION

Use of -Authored Prehistory to Improve Patient Experiences and Accommodate Federal Law Michael J. Warner, DO, CPC; Thomas J. Simunich, MS, MBA; Margaret K. Warner, DO; and Joseph Dado, MS

From Patient Context: Although federal law grants the right to view and amend their medi- Advocacy Initiatives cal records, few studies have proposed a process for patients to coauthor their subjec- (Drs M.J. Warner and M.K. Warner) and Conemaugh tive history in their . Allowing patients to fully disclose and document Memorial Medical System their medical history is an important step to improve the diagnostic process. (Mr Simunich and Mr Dado) in Johnstown, Pennsylvania. Objective: To evaluate patients’ office experience before and after they authored their subjective medical history for the . Financial Disclosures: None reported. Methods: Patients were mailed a prehistory form and presurvey to be completed Support: None reported. before their family medicine office visit. On arrival to the office, the prehistory form

Address correspondence to was scanned into the electronic health record while the content was transcribed by Michael J. Warner, DO, CPC, staff into the appropriate fields in the history component of the encounter Initiatives, note. Postsurveys were given to patients to be completed after their visit. Pre- and 130 Jennie Ln, Johnstown, PA postsurveys measured the patients’ perception of office visit quality as well as com- 15904-1200. pleteness and accuracy of their electronic health record documentation before and E-mail: drmichaelwarner@ after their appointment. Medical staff surveys were collected weekly to measure patientadvocacyinitiatives.org the staff’s viewpoint of the federal law that allows patients to view and amend their Submitted medical records. October 15, 2015; final revision received Results: Of 405 patients who were asked to participate, 263 patients aged 14 to May 18, 2016; accepted 94 years completed a presurvey and a prehistory form. Of those 263 patients, July 13, 2016. 134 completed a postsurvey. The pre- and postsurveys showed improved patient sat- isfaction with the office visit and high scores for documentation accuracy and com- pleteness. Before filling out the prehistory form, 116 of 249 patients (46.6%) agreed or strongly agreed that they felt more empowered in their health care by completing the prehistory form compared with 110 of 131 (84.0%) who agreed or strongly agreed after the visit (P<.001). Staff members agreed that patients should have the right to view and amend their medical records in accordance with federal law.

Conclusion: Empowering patients to contribute subjective information to their elec- tronic health record has the potential to improve the diagnostic process. When con- ducting a medical encounter, the authors recommend having patients complete a prehistory form beforehand to improve the patient experience while accommodating federal law.

J Am Osteopath Assoc. 2017;117(2):78-84 doi:10.7556/jaoa.2017.018

Keywords: electronic health record, diagnostic errors, patient-authored history, prehistory

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ccording to Improving Diagnosis in Health racy. With electronic health record (EHR) patient por- Care (Quality Chasm),1 the latest of a tals and portable computer devices, patients can more A series by the Health and Medicine Division easily access such information. Although federal law in the National Academies of Science, Engineering, gave patients the right to amend and view their medical and Medicine (previously the Institute of Medicine), records more than a decade ago, few patients work with most people in the will experience at health care professionals to input information. We be- least 1 diagnostic error, sometimes with devastating lieve that the traditional verbal question-and-answer consequences. Diagnostic errors and problems with the format of a patient history limits the diagnostic process. diagnostic process account for 10% of patient deaths in As a solution, we implemented a patient-completed the United States.1 The authors cite improvement of the prehistory form at a family medicine practice in a small diagnostic process as “a moral, professional, and public Pennsylvania town. health imperative.”1(p2) As part of the solution, the report The present study was designed to allow for patient recommends participation of patients and family mem- and family member participation in the diagnostic pro- bers to improve the diagnostic process and to reduce cess to improve the accuracy and content of the patient’s errors.1(pp358-363) Family members may spend continuous subjective story. We invited patients to coauthor the his- time with patients and are aware of circumstances that tory component of their EHR using a prehistory form, should be communicated to health care professionals. which includes the same information in the history note Patients have a federal right to view and amend required for documentation. Beyond diagnostic accu- their medical records.2,3 Compliance with the Stan- racy, we focused on patients’ experiences about contrib- dards for Privacy of Individually Identifiable Health uting to their medical record. We hypothesized that Information (ie, the Privacy Rule) by health care pro- patients would be most satisfied with the documentation fessionals was required as of April 14, 2002, and is a of their medical stories if they had an opportunity to final rule of the Portability and Ac- write the information themselves. We also measured staff countability Act of 1996.4 Health care professionals members’ understanding of federal law and attitudes to- must accommodate or respond to a patient’s request to ward the prehistory form. amend his or her medical record within 60 days or face a potential violation. Health care professionals may either make the amendment or offer a written Methods explanation to the patient as to why the task could not An invitation packet was mailed to patients 1 week be- be completed. The US Department of Health and fore their office visit with the physician (M.J.W.) from Human Services’ Office for Civil Rights is responsible mid-March to mid-May 2015. Patients who had a for enforcement, which includes complaint investiga- scheduled visit a week before the prehistory packet was tions and compliance reviews. That office can assign mailed were included. No exclusion criteria were used. civil money penalties and criminal prosecution. A The physician’s schedule was not altered to accommo- government online complaint portal (https://ocrportal. date this study. Patients were typically scheduled for a hhs.gov/ocr) and toll-free telephone support (1-800- 15-minute visit, with a maximum of 3 patients per hour. 368-1019) exist to receive complaints and initiate Participation was voluntary, and patients were not com- investigations. pensated in any manner for their participation. The in- The intent of the Privacy Rule was to give patients stitutional review board at Conemaugh Memorial the ability to view their medical record to ensure accu- Medical Center approved this study.

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The packet included an invitation letter, a blank Every part of the prehistory form had a correlating paper prehistory form, 2 sample prehistory forms, location in the history component of the encounter and a presurvey. Each sample prehistory form de- note in the EHR. All prehistory forms were shredded scribed 1 of 2 vignettes: new problem and status of after they were scanned into the EHR and informa- chronic disease. Whether they had 1 or many new or tion was entered. chronic problems, patients were instructed to com- After transcription, the physician entered the exami- plete the prehistory form to take with them to their nation room and greeted the patient. After reviewing the upcoming appointment. patient-authored history in the EHR, the physician asked The welcome packet encouraged patients to have a additional questions and conducted a pertinent examina- family member or friend help them to the complete the tion, followed by medical decision making. form. The prehistory form requested the same history At the conclusion of the office visit, each patient was information required for documentation by the Centers given a printed copy of his or her encounter note and a for Medicare and Medicaid Services5 and is available 9-question postsurvey. In the postsurvey, patients were free of charge.6 asked about their office note, perceptions of satisfaction, The 3-page prehistory form included blank lines for self-empowerment, appreciation, and the extent to which patients to write responses. Chief complaint, status of they felt better heard and understood. Patients were in- chronic disease(s), history of present illness, and family structed to first read the encounter note, complete the social history were listed. The history of present illness postsurvey, and mail the survey anonymously to our of- was further divided into 8 components: location, quality, fice. Completed postsurveys were placed in a secured severity, duration, timing, context, modifying factors, box and collected weekly. This study required the physi- and associated signs and symptoms. Short descriptors cian to complete the encounter note at the time of service help define components, such as “where on body?” for so that patients could receive a printed copy of the note at location and “how long has it been occurring?” for dura- the end of the visit. tion. The prehistory form also allowed for a 14-system Staff members (comprising an osteopathic family query for review of systems. physician, a registered nurse, a licensed practical The presurvey asked patients to answer 7 survey nurse, 2 medical assistants, and 2 medical secretaries) items regarding their perceptions of satisfaction, self- were distributed a 7-question survey by hand at the empowerment, appreciation, and the extent to which beginning of the 2-month study, at the end of every they felt better heard and understood. Satisfaction was week during the study, and at the conclusion of the rated on a 10-point Likert-type scale, with 0 indicating study. The 7-question survey asked staff members not satisfied at all and 10 indicating very satisfied. The about their duties and understanding of the federal law remaining perceptions used a 5-point Likert scale, and attitudes toward the prehistory form. These sur- with 1 indicating strongly agree and 5 indicating veys allowed them to express their views regarding strongly disagree. in the EHR review and amend- Office visits began with the submission of the ment process. Each staff member had an opportunity prehistory form and the presurvey. Staff members to identify him- or herself as having roles either at the were instructed to scan the prehistory form into the welcome window, triage station, or check-out window EHR and title the document as “PreHx.” The content or as a physician. After staff members completed the was entered into the history component of the med- survey anonymously, the surveys were placed in a se- ical encounter note exactly as written by the patient. cure box.

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Results amendment process, 1 patient wrote that he or she Of 405 patients who were asked to participate, 263 did not want to fill out any more forms. Three pa- (64.9%) returned the prehistory forms. Of 263 pa- tients wrote that there was little need to complete tients, 152 (57.8%) were men, and 100 (38.0%) were such a form because they trusted their physician. women. Eleven patients did not report their sex. Overall, patients exhibited support for the opportu- The patients’ ages ranged from 14 years to 94 years. nity to contribute to their EHR. This sentiment in- Three patients were younger than 18 years. The creased after the visit and after viewing their mean age of men was 64 years, and the mean age of encounter note. One patient wrote: “I loved com- women was 63 years. No statistically significant dif- pleting the PreHx. It gave me time to reflect on the ference was found based on age by sex using indepen- questions and answer them without rushing.” Several dent samples t test (P=.665). No response bias on the patients remarked that they often forgot to ask ques- basis of sex was found. tions at previous office visits but were able to ad- Overall, 263 of 405 patients (64.9%) returned the dress all their concerns with the prehistory form. presurvey, and 134 of those 263 (51.0%) returned Patients’ comments supported the belief that because the postsurvey. Patients anonymously completed the of the prehistory form, physicians were able to spend pre- and postsurveys. The average response rate per more time focusing on their needs during office question for the 9-question postsurvey was 52%. visits. They also said that the visit seemed longer and After adjusting the overall α=.05 with a Bonferroni more directed toward their concerns. Patient scores correction to yield a testwise α=.0125, the change in re- were mixed as to whether they wanted to access their sponse regarding empowerment, appreciation, and being medical records online. Some patients expressed a understood were found to be statistically significant mistrust of EHR security. using an independent sample t test on the mean and the The staff survey results revealed that all staff Mann-Whitney U test on the response distribution members agreed that patients are allowed to view (P<.005). and amend their medical record according to federal Patients felt more empowered in their health care by law and concurred with the idea and practice of pa- completing the prehistory form (Table). Overall, 116 of tients’ coauthorship of their medical records. Al- 249 patients (46.6%) answered “agree” or “strongly though the strength of their agreement improved agree” before filling out the prehistory form compared throughout the study, the change was not statisti- with 110 of 131 (84.0%) after the visit (P<.001). Addi- cally significant. In the comment section of the tionally, 167 of 260 patients (64.2%) demonstrated a survey, the staff noted that they believed the prehis- greater appreciation of their chance to coauthor their tory form should be an automated feature of the EHR compared with 116 of 132 (87.9%) after the visit patient portal. (P<.001). In total, 145 of 254 patients (57.1%) felt that The physician felt that by reading the patient- submitting a prehistory form allowed them to be better authored history, he better understood his patients’ heard and understood compared with 112 of 131 problems and concerns. He wrote, “Once I read the (85.5%) after the visit (P<.001). Not all patients an- PreHx, it was as if we had already been talking for swered every question. fifteen minutes. Data from the PreHx allowed me to Eighty-two comments were written on 82 patient ask more specific questions. Because patients actively pre- and postsurveys. When asked about their views engaged in their care, they were better able to partici- on patient participation in the EHR review and pate in shared decision-making.”

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Table. Patients’ Pre- and Postsurvey Responses About the Prehistory Forma

Likert Time Difference in Percent Change Survey Item Scaleb Point N Mean Means (Post–Pre) (Post–Pre)/Pre P Value

How satisfied were you with your 0-10 Pre 225 9.5 0.2, improved 2% .048c,d experience as a patient in this office? Post 134 9.7

Completing the prehistory form made me 1-5 Pre 249 2.5 −0.5, improved −20% <.001c,d feel more empowered in my health care. Post 131 2.0

I appreciate being given the chance to 1-5 Pre 260 2.2 −0.4, improved −18% <.001c coauthor my medical record. Post 132 1.8

I feel that I will be better heard and 1-5 Pre 254 2.4 −0.5, improved −21% <.001c,d understood by having submitted a prehistory. Post 131 1.9

a The presurvey was completed at the time that the prehistory form was completed and collected at presentation to the office. The postsurvey was distributed after the office visit and mailed to the office. b Satisfaction was rated on a 10-point Likert-type scale, with 0 indicating not satisfied at all and 10 indicating very satisfied. The remaining perceptions used a 5-point Likert scale, with 1 indicating strongly agree and 5 indicating strongly disagree. c Some violation of normality assumption. d Unequal variances assumed.

Discussion history to hematemesis converts the vernacular into Sir William Olser said, “Listen to the patient, he is telling medical terminology but strips away the patient’s per- you the diagnosis.”7 Despite advances in modern medi- spective. The current study preserved the subjective ex- cine, experts rate the conversation between patient and perience by using and emphasizing the patients’ words. physician as more important than either the physical ex- Medical questionnaires have been studied as an ad- amination or laboratory investigations to make an accu- junct to physician interviews with patients. In 1949, the rate diagnosis.8 Cornell Medical Index was found to be a quick and reli- Traditional history taking has deficits related to com- able method of obtaining patient information.15 Written pleteness and time required by the physician to obtain or computer-automated questionnaires were also found and document information.9 The history should include to be more accurate and complete than traditional physi- as much detail as required to retell the story,10 but 77% of cian history taking.7 physician-generated interviews fail to fully elicit and Although we did not measure time as a factor in the document their patients’ reasons for visiting the current study, we did maintain a 15-minute visit physician.6(p10) In light of EHRs with templates and copy- schedule. We believe that less time was spent discussing forward functions, some histories contain information medical history, which allowed for deeper questioning that is incomplete, inappropriate, fraudulent, or “down- and more shared decision making. right factitious.”10-12 Allowing patients to tell their story and have it docu- Medical narratives tend to neglect or objectify the mented in the EHR gives respect to the patient. The pro- patient’s subjective experience, including symptoms.13 cess of accommodating a patient’s right to amend and Although it is the responsibility of the physician to trans- view the entire medical record speaks to medical core late “lay” narrative into medical constructs, physicians competencies,16 including patient care, interpersonal and must avoid misinterpretation or alteration of the patients’ communication skills, professionalism, practice-based actual experience.6(p102),14 Changing vomiting blood in the learning and improvement, and systems-based practice.

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Patient participation in the medical record extends the Limitations moral obligation to improve the diagnostic process be- In the current study, we used paper forms because yond health care professionals to patient responsibility, paper is inexpensive and easily mailed. If we had an obligation, and duty to assume an active role in health electronic version built into the EHR patient portal, care. We envision an evolution of the patients’ role as staff members could avoid potentially introducing er- consumers of health care. rors by scanning the document and transcribing the The Medicare Access and CHIP Reauthorization Act information. calls for patient-generated health data as part of the ob- All patient pre- and postsurveys were aggregated. We jective to coordinate care through patient engagement.17 could have linked each patient’s surveys together by By accommodating a patient-authored history, the cur- embedding barcodes into the documents to produce more rent study demonstrates a process that achieves this accurate statistical information, but we chose not to be- objective. cause of the potential perception of privacy loss and the The current study recognized the patients’ prehistory cost of logistical management. form as a written request to amend the medical record. The present study did not assess the educational or Although the law permits 60 days to approve or deny an literacy level of our patients. Some patients may not have amendment, the current study allowed for immediate participated because of illiteracy. Some patients com- acceptance. In addition to scanning the prehistory form pleted the prehistory form with the help of a family into the EHR, we entered the patients’ narrative into the member or friend. Further exploration will likely identify history component of the encounter note to be shared ways to promote family and friend participation, per the with all current and future health care professionals. We Health and Medicine Division’s recommendations.1 believe that a strong history will result in an improved The current study did not film the face-to-face en- diagnostic process. counters to compare prehistory vs nonprehistory visits. The Health and Medicine Division report1 validates Analysis of such encounters would likely reveal deficits the attainability of solutions to the diagnostic process. and opportunities for improving the diagnostic process. This view bolsters our belief, therefore, that all health care professionals should be able to accommodate their patients’ self-authored history. We encourage EHR sys- Conclusion tems to include a prehistory note as part of every patient Patients have a federal right to view and amend their portal to allow patients to participate interactively with medical records. Allowing patients to complete a prehis- their medical records and freely address their subjective tory form and incorporating the information into their concerns. medical record resulted in high scores for documenta- In Improving Diagnosis in Health Care (Quality tion, along with greater patient satisfaction with the Chasm),1(pxiii) physicians are called to view patients as medical encounter. We believe this type of patient par- central to minimizing diagnostic errors. We recognize the ticipation has the potential to improve EHR content and patient’s voice as a missing piece of the medical record accuracy, as well as the diagnostic process. Completing and remedied it with a patient-authored history. We a prehistory form enabled patients to feel empowered in joined the patient and the physician together in a partner- their health care. We recommend the use of a patient- ship in health care. Rather than call for new rules, the authored history as a practical and effective means of present study followed federal laws and facilitated pa- documenting patients’ stories and encouraging them to tients’ active participation. become active consumers of health care.

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Author Contributions 8. Cole SA, Bird J. The Medical Interview: The Three Function Approach. 3rd ed. Philadelphia, PA: Elsevier Saunders; 2014:9. Drs M.J. Warner and M.K. Warner and Mr Simunich provided substantial contributions to conception and 9. Bachman JW. The patient-computer interview: a neglected design, acquisition of data, or analysis and interpretation tool that can aid the clinician. Mayo Clin Proc. 2003;78:67-78. of data; all authors drafted the article or revised it critically 10. Kuhn T, Basch P, Barr M, Yackel T; Medical Informatics for important intellectual content; all authors gave final Committee of the American College of Physicians. Clinical approval of the version of the article to be published; documentation in the 21st century: executive summary of and Drs M.J. Warner and M.K. Warner and Mr Simunich a policy position paper from the American College of Physicians. agree to be accountable for all aspects of the work in Ann Intern Med. 2015;162(4):301-303. doi:10.7326/M14-2128 ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated 11. Zakim D, Braun N, Fritz P, Alscher MD. Underutilization and resolved. of information and knowledge in everyday medical practice: evaluation of a computer-based solution. BMC Med Inform Decis Mak. 2008;8:50. doi:10.1186/1472-6947-8-50

References 12. Skolnik N, Notte C. Whispered pectoriloquy. 1. Balogh, EP, Miller BT, Ball JR, eds. Improving Diagnosis Family Practice News. August 4, 2015. in Health Care (Quality Chasm). Washington DC: 13. Donnelly WJ. Righting the medical record: transforming National Academies Press; 2015. chronicle into story. JAMA. 1988;260(6):823-825.

2. Access of Individuals to Protected Health Information, 14. Larsen JH, Neighbour R. Five cards: a simple guide 45 CFR §164.524 (2002). to beginning the consultation. Br J Gen Pract. 3. Amendment of Protected Health Information, 2014;64(620):150-151. doi:10.3399/bjgp14X677662 45 CFR §164.526 (2002). 15. Brodman K, Erdman AJ Jr, Lorge I, Wolff HG, Broadbent TH. 4. Compliance Dates for Initial Implementation The Cornell medical index; an adjunct to medical interview. of the Privacy Standards, 45 CFR §164.534 (2002). JAMA. 1949;140(6):530-534.

5. Department of Health and Human Services, Centers for 16. American Association of Colleges of Osteopathic Medicine Medicare & Medicaid Services. Evaluation and management (AACOM). Osteopathic Core Competencies for Medical services. https://www.cms.gov/Outreach-and-Education Students. Chevy Chase, MD: AACOM; August 2012. /Medicare-Learning-Network-MLN/MLNProducts/Downloads https://www.aacom.org/docs/default-source/core /eval-mgmt-serv-guide-ICN006764.pdf. Updated August 2016. -competencies/corecompetencyreport2012.pdf?sfvrsn=4. Accessed December 2, 2016. Accessed December 19, 2016.

6. Welcome to Patient Advocacy Initiatives. Patient Advocacy 17. Medicare program; merit-based incentive payment system Initiatives website. http://patientadvocacyinitiatives.org. (MIPS) and alternative payment model (APM) incentive Accessed December 2, 2016. under the physician fee schedule, and criteria for physician- focused payment models. Fed Regist. 2016:81;28222-28228. 7. Silverman ME, Murray, TJ, Bryan CS. The Quotable Osler. Philadelphia, PA: American College of Physicians; 2008:98. © 2017 American Osteopathic Association

Peer Reviewers Wanted Peer reviewers are physicians, basic scientists, and other health care professionals who critically evaluate the scientific quality and clinical significance of research submitted toThe Journal of the American Osteopathic Association. The JAOA is currently looking for persons interested in serving as peer reviewers. For additional information, visit http://jaoa.org/ss/reviewers.aspx. Prospective peer reviewers can also contact the JAOA’s editorial assistant at [email protected].

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