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Instant Medical History™ (IMH) is a computerized patient interview about the history of present illness, review of systems, and medical history. IMH asks the patient questions to give the physician caring for the patient more information prior to the visit. The information is summarized and passed to the (electronic) medical record, reducing the interview time and documentation requirements for the physician. The AAFP article shows it could save 5 minutes of physician time per visit.
Instant Medical History™ is useful in 98% of the chief complaints seen by a family physician or internist. There is a relevant questionnaire for 80-90% of the complaints seen by specialists. We are also able to add questionnaires very quickly for patient complaints that do not have existing questionnaires.
IMH helps with the doctor-patient relationship and the medical interview. This software program simply gathers data. Data gathering enhances doctor-patient communication by giving the physician more information before seeing the patient to better evaluate the problems. Physicians will still interview the patient to get a personal feel for the individual. The software simply helps start the process by giving the physician areas to focus upon, and providing documentation of the negatives. Not many physicians can remember all of the questions to ask about every presenting complaint in medicine much less document them thoroughly for third party review. Another helpful use it to save the physicians from having to find paper forms for standardized self rating scales and scoring them during the patient visit.
There are a number of reasons why a specialist would want IMH to collect the patient history:
Interview software takes longer than a physician would to gain the same information. If you normally take 5 minutes to gather the patient’s history, Instant Medical History™ will require 10 minutes. The average interview takes less than 10 minutes, but keep in mind that patient entered data is free. It is patient time instead of physician time.
A valuable implementation of Instant Medical History™ is on a physician’s web site. By having the patient complete the interview at home before the visit, the time the patient takes to complete the interview does not change the office workflow or require the patient to arrive early at the office to complete the data entry.
Use the Level of Detail settings to reduce the amount of information. Learning to review the information presented by Instant Medical History™ takes some time. After that, the assimilation of the history of the present illness takes only the few seconds.
The output of Instant Medical History™ is absolutely essential if physicians are going to be paid for their work. Only by documenting to the highest levels will they be paid for the work they actually do by third parties. Since the information from Instant Medical History™ is gathered directly from the patient, its authenticity is unquestioned by third-parties once reviewed by the physician.
Nothing. You have screened for literacy. Valuable information is gained if a patient is known to be illiterate. Patients who can’t read should not be given pills that are the same color. An illiterate patient given two small white pills, Lanoxin and Lasix, and told to double his Lasix will be dead. Written instructions will be worthless. Most patients will not admit that they cannot read, but rather they will say that they 'forgot their glasses'. The output from the illiterate patient will be obvious when reviewed by the clinician. Unless the patient walked to the office, someone who could read in order to pass the drivers test brought the illiterate patient to the facility. These family members can read the questions to the patient. These individuals are also free resources and willing assistants for the medical office.
The same thing that happens when you get a spurious laboratory result, clinical judgment is necessary to determine why. This is the main reason that computers will never replace physicians, only help them. Patient provided data must be verified by the clinician since it is raw data directly from the patient. The information must be filtered by the practitioner before it has merit. Usually the practitioner asks open ended questions directed by the input. If the data doesn’t correlate with the clinician’s impression, then there are three possibilities: 1) the patient could not read and pretended to; 2) the patient has an organic brain syndrome, tried to hide his mental disability, and could not manipulate the instructions for the screening, 3) the patient willfully attempted to deceive the program to hide something from the provider, e.g. drug seeking or malingering.
Every practicing physician asks more questions in a medical interview than documented on the office visit note. Every physician takes a better medical history than is apparent from a medical chart review. IMH simply records data to justify charges deserved anyway. The third party notion that if it is not documented, it didn’t happen, is reality. IMH allows the physicians to get paid for what they were really doing all along but did not have time to record. The additional documentation of self rating scales is an added benefit that is also good quality medical care. CPT Procedure Code 96103, Computerized Assessment/Psychological Test, allows the physician the potential to review the written report output by IMH in order to be reimbursed. It is cheaper and better medicine to get the diagnosis of psychological disorders earlier and avoid unnecessary tests and procedures. You will need to verify this type of reimbursement with your payers.
Health Maintenance guidelines are optionally embedded in the program to allow every patient to be queried for preventive measures like immunizations, mammograms, and blood tests depending on age and risk factors. Many electronic medical record systems record this information as well, but by asking the patient directly, the medical record information is verified as correct. In a fee for service patient, increasing the number of elective procedures can have a substantial impact on revenue.
When higher levels of care are rendered, higher fees are justified. The higher levels require the extensive documentation which IMH provides. For example, documentation of a majority of the qualifiers of a symptom range from onset, duration, severity, location, radiation, ameliorating factors, exacerbating factors, and social concomitants. Documentation of a Review of Systems requires notation of eleven of fourteen organ systems.
Recent CMS rules specify extensive documentation guidelines. If your charts are audited and the documentation is not clear to the chart reviewers, you could be asked to refund payments and charged with Medicare fraud. For example, suppose you performed a health screening exam on a 70 year old well adult and your notes do not reflect positives and negatives for eleven of fourteen organ systems, a complete Social History including sexual activity and a Family History. You may be asked to return the fee difference for the payment for the extended office visit and an ordinary office visit. This denial will likely trigger a deeper audit of your charts which may result in every detailed or comprehensive examination charge you have made for several years being subject to refund, penalty, fine, and prosecution for Medicare fraud.
Literature on filling out forms versus computer interviewing is over 50 years old. If you go to the Mayo Clinic Proceedings January 2003, there is a review of the literature. It cites the disadvantages of forms as (1) Patients do not complete the form without skipping questions. The problem the clinician faces is that if the form is not filled out completely the clinician is responsible for ensuring that this is corrected. Mayo found 10% of forms were missing information. (2) Forms do not branch enough. There is an excellent study showing how Mayo failed trying to use forms to prepare patients for specialties. (3) Forms also have difficulties with changes. For example, if there is a SARS epidemic you need to add four questions to your histories. The American Family Physician in one year had 44 forms it published to help clinicians practice better by providing more data. (4) Forms create an extra layer of HIPAA concern - the office must be sure to find and secure each and every form. In summary, patients prefer computers to forms and provide better data with a computer.
The questions are answered by the patient. There are two formats: Nurse and Patient. The formats have to do with who makes the decision about the presenting compliant through the menu selections to get to the actual questions. The Nurse format is intended for the exam room. The Patient format is intended for the waiting room. The menus can be totally patient driven (Patient Waiting Room Format) or initiated by the nurse (Nurse Exam Room Format) and then patient driven for the actual questions.
Patients who are the most difficult for you as a physician will prove to be the best for the computer. Humans do high level integrative tasks well. Arriving at a diagnosis after reviewing data gathered from a history, physical examination, and laboratory investigation is an example of a complex integrative task that we do well. Computers do low level tasks that are repetitive, boring and monotonous very fast. Asking all of the questions related to a complete Review of Systems is a mundane task that physicians do every day over and over again that a computer could do well. If the medical history is obvious, a broken arm for example, then there is no reason to use a computer. A good rule of thumb is that if the nurse knows the diagnosis before the physician, then the computer is not going to help very much except as ancillary documentation.
You may find it easier to be a physician because a boring, monotonous part of your job is done - data gathering and documentation. When you gain confidence in IMH, you will find your efficiency of seeing patients increases because you have an electronic assistant that makes your job easier. This electronic assistant will ask questions as consistently at 4PM on Fridays when the waiting room is full as it does at 8AM on Mondays after you return from a vacation. That consistency can facilitate better medical care.
More importantly Instant Medical History™ will help you have the documentation recorded in your medical record to charge for the services that you are performing. The financial benefit of installing Instant Medical History can be substantially increasing revenue to a physician.
Over 40 EMRs have, and more commit each year. There are lots of reasons why EMR makers haven't put Instant Medical History™ into their system but the biggest reason is that users haven’t asked for it!
LSU and the University of Wisconsin have both published studies indicating that almost 90% of patients want to complete Instant Medical History. When you focus on patient satisfaction, communication is the top issue. Because the questionnaires are about them, patients perceive that the computer assists physicians in discussing the most important items. Within the limited time of a visit, physicians and patients communicate faster about the important issues, creating a stronger physician-patient bond. Practices using Instant Medical History find that their patient satisfaction increases from this.
The minimum configuration should be:
For Mood Disorders the most prominent of which is bipolar disorder, use the Mood Disorder Questionnaire. MDQ is a standardized instrument and is very helpful for use in patients who fail the mental health screen, but pass the follow up questionnaires for stress, anxiety, and depression.
For suspected Adult Hyperactivity, use the Adult ADHD Self report scale screening. You can get this by entering "ADD" for example. This screens for both bipolar and Adult ADHD. Note if the patient denies difficulty with concentration or hyperactivity, then the Adult ADHD scale is not triggered. If you want the scale to work regardless of the patients symptoms, enter "adult ADHD self-report scale."
Thank you again for your interest in Instant Medical History.