History of patient charting

The earliest patient records, dating back to “antiquity,” were created for instructional and educational purposes at least 4,000 years ago. Written case history reports were found to have been developed for didactic purposes by medieval physicians. The forerunner of modern medical records, researchers have discovered, “first appeared in Paris and Berlin by the early 19th century.” It was not until the 20th century that “a clinical medical record useful for direct patient care in hospital and ambulatory settings” was developed and used regularly.

By the early 20th century, healthcare providers were charting patient visit notes and medical history to be used in the treatment of those patients. According to an article published by Rasmussen College, “Documentation became wildly popular and was used throughout the nation after healthcare providers realized that they were better able to treat patients with complete and accurate medical history. Health records were soon recognized as being critical to the safety and quality of the patient experience.”

Patient charting was standardized by the American College of Surgeons (ACOS), which established the American Association of Record Librarians. Today the association is known as the American Health Information Management Association (AHIMA). Paper patient charts were handwritten and kept in files on specially designed shelves until the mid to late 20th century, when new technology was being developed.

Throughout the late 20th century, patient charting began to be moved into electronic systems. The electronic health record (EHR) was originally developed for hospitals and universities, but by the 1980s, more focused efforts were made to increase the use of EHR among medical practices. While manual patient charting and filing was vulnerable to errors, the Centers for Medicare & Medicaid Services (CMS) recognized that the EHR “can improve patient care by:

• Reducing the incidence of medical error by improving the accuracy and clarity of medical records.
• Making the health information available, reducing duplication of tests, reducing delays in treatment, and patients well informed to take better decisions.
• Reducing medical error by improving the accuracy and clarity of medical records.”

Patient charting has advanced significantly in the past 4,000 years. In the 21st century, patient data can be accessed and shared seamlessly among providers caring for the patient, through EHRs. The primary care physician now has the ability to coordinate care electronically and accurately, ensuring the highest quality outcomes.

Damien Neuman
January 9, 2019

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Latest findings show value-based care impact on preventative care and care quality

Preventive screenings occurred at a higher rate under value-based care than with physicians in a fee-for-service arrangement, according to the latest report published by Humana, a healthcare payer. The Value-Based Care Report published annually for the past five years, examines the physicians within the Humana system and their impact on patients. Chronic condition management also improved with the value-based care model.

The report cites the example of breast cancer screenings, in which “patients affiliated with physicians in value-based care agreements had a higher frequency rate of breast cancer screenings (78 percent) compared to patients affiliated with physicians in fee-for-service (69 percent) and fee-for-service plus bonus agreements (69 percent).”

An increase in preventive screenings was also found among patients in value-based care for osteoporosis management, rheumatoid arthritis management, blood pressure control management, statin medication adherence, high blood pressure medication adherence, and adult BMI assessment. 83% of patients showed improved adherence to statin medication in value-based care, as contrasted with 79% of patients in the fee-for-service model. Medication reviews for older adult patients were reported at 96% in value-based care and 88% in fee-for-service care.

Humana reported that their physicians practicing in “value-based agreements had more favorable results than physicians in fee-for-service agreements in all HEDIS (Healthcare Effective Data and Information Set) Star measures.” Further, the report states, “Focusing on prevention and the whole health of their panel population allows physicians and their care teams to work more strategically to improve the care of their patients, thus keeping them home and out of the hospital and emergency room.”

Emergency room visits and hospital admissions were also significantly lower in the value-based care models than with fee-for-service physician practices. Proper and timely preventive care has been shown to have a significant impact on hospital stays as well. Overall, the report states, “physicians who practice value-based care are achieving higher rates of patient engagement in preventive screenings, medication adherence and management of chronic conditions as measured by HEDIS.”

Damien Neuman
December 14, 2018

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Panel discusses changing primary care landscape

Reimbursement challenges, changing preferences among younger patients, and an aging population who need expanded access were all topics in a recent panel discussion on the current and future state of primary care in this country. The discussion took place among participants in the Cleveland Clinic 2018 Medical Innovation Summit and involved a look at the possible future of primary care.

Experts on the panel included Anil Jain, MD, VP & Chief Health Information Officer, IBM Watson; Peter Antall, MD, President & CMO, American Well; Joe Schrick, Vice President Fitness Segment, Garmin; Bonnie Clipper, Vice President of Innovation, American Nurses Association; and Nirav Vakharia, MD, Vice Chair, Population Management, Cleveland Clinic.

The general consensus was that primary care is changing and is faced with a number of challenges, particularly those around reimbursement and the time spent on earning those payments. Physicians are being asked to focus on value-based care, which may involve extensive reporting and adhering to new regulations established by the Centers for Medicare & Medicaid Services (CMS) for their Medicare patients. The panel discussed their view that physicians are spending too much time on administrative work, which takes away from the time they can spend with their patients.

Additionally, the varying demands and preferences of the generations was discussed. Millennials and younger patients are very technology-oriented. They tend to take advantage of wearables and apps, prefer telemedicine over in-person visits, and engage in technology that monitors their health and fitness. The challenge with this dependency on technology, noted the panel, is that there is no primary care physician involved to coordinate care that may be necessary for an injury or illness.

On the other end of the generational spectrum, as the patient population ages, more elderly patients are finding they cannot access primary care for various reasons. A tendency toward chronic and complex conditions in older patients requires more of the primary care physician’s time and, again, reporting requirements at the CMS level for incentives and reimbursements.

The panel moderator, Dr. Jain, noted that “We know that primary care is under siege. We have a lot of transformation happening in health. Primary care doctors and primary care practitioners are being asked to deliver high quality and high value care. But they’re not being given all the necessary tools to do so.”

Damien Neuman
December 10, 2018

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Why doctors who work in small, independent primary care practices may have lower rates of physician burnout

About half of all physicians experience burnout, according to multiple studies conducted of physicians who work in hospital settings, for large practices, and for themselves. However, when studies are conducted of independent physicians specifically, that burnout level tends to be significantly lower. A limited study of independent primary care physicians published recently in the Journal of the American Board of Family Medicine found that their burnout rate was only 13.5 percent.

An article published in AMA-Wire suggests a number of reasons for the lower burnout rate among independent primary care physicians:

Autonomy. Independent primary care physicians have more control over their administrative tasks, their work hours, and their overall working environment. This control helps reduce the amount of stress that may typically be found in a hospital or other healthcare facility, in which the primary care physician reports to a higher administrative level. The AMA article points out that previous studies have determined that “low work control and low autonomy has been linked with higher levels of burnout.”

Deeper relationships with patients. Along with that autonomy comes the ability to spend more time with patients, to communicate with them outside the office visit, and to get to know them better. Engaging with patients is the primary focus of most independent physicians’ work, so developing that deeper relationship with patients may lead to higher levels of job satisfaction and lower levels of burnout.

Fewer work hours. Independent primary care physicians establish their own office hours and have more control over their work schedule than those working for larger practices or for healthcare facilities. Exhaustion is a significant factor in burnout, so fewer work hours contribute to less stress and fatigue.

Higher adaptive reserve scores. The researchers who conducted the study of independent primary care physicians defined “adaptive reserve” as the independent physician practice’s “internal capacity for organizational learning and development.” The organizational capacity for change and for growth is much higher in an independent primary care practice and that can also lead to lower rates of physician burnout.

Damien Neuman
December 3, 2018

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The primary care preferences of millennials

Millennials comprise the group of people born in the last twenty years of the twentieth century. Although specific birth years vary from one generational expert to another, millennials were born between about 1981 and the turn of the century. There are about 83 million millennials in the US. This group of people has grown up immersed in technology, with a completely different view of the world than their Generation X or Boomer parents. Moving from job to job, from city to city, is not unusual for this group. They look for expediency, convenience, and immediate rewards.

Millennials also have a different view of medical care than the older generations. While a Boomer may develop a long-lasting relationship with a primary care physician, a 2017 survey conducted by the Employee Benefit Research Institute, a Washington think tank, and Greenwald and Associates found that 33 percent of millennials did not have a primary care physician. In that same survey, the researchers found that only 15 percent of those age 50 to 64 did not have a regular doctor.

Speed and convenience are the primary concerns for millennials, particularly in regard to how they access healthcare. In fact, these trends are being seen in other age groups as well. As internist Ateev Mehrotra, an associate professor in the Department of Health Care Policy at Harvard Medical School, noted in a recent Washington Post article, “Younger patients are unwilling to wait a few days to see a doctor for an acute problem, a situation that used to be routine.”

Millennials also want connectivity. Primary care physicians who offer the ability to communicate electronically, to access telehealth services, and to make appointments online or through an app will be more attractive to that busy age group. Those appointments also need to be speedy and on time. A millennial typically wants to be seen the same day or the next day and does not want to be kept waiting when the appointment time arrives.

Millennials prefer the convenient access of an urgent care or even an emergency room for their healthcare services. Primary care physicians such as Mott Blair, a family physician in Wallace, N.C., are adjusting to their patients’ preferences, including reaching out to millennials who need the holistic and consistent healthcare that is not typically available at urgent care centers.

Damien Neuman
November 29, 2018

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What are social determinants of health relevant to value-based care and primary care physicians?

Providing value-based care requires a focus on overall health outcomes for the patient, a shift from the traditional fee-per-visit model of care that is focused on individual office visits. The primary care physician must look at the complete picture of a patient to understand what factors impact that patient’s current condition and future health. In addition to the usual factors of genetics, diet, and exercise, social determinants of health can also affect the patient’s well-being.

Social determinants of health include socioeconomic factors, education level, economic environment, job opportunities, and social supports, “conditions in the places where people live, learn, work, and play” that “affect a wide range of health risks and outcomes.”

Socioeconomic factors are significant social determinants of health. Patients who are low-income may be challenged with finding a job because of the economic environment in which they live, a lack of education or training, or other reasons related to their background or environment. When considering socioeconomic factors, the primary care physician must understand whether an order to eat healthier can actually be carried out by the patient who may face challenges with being able to purchase high quality food.

Simple access to healthcare can also be a barrier for the primary care physician’s patients. Transportation may not be available or the patient may not be able to afford transportation to the provider’s office. Providing value-based care to these patients may require innovative solutions such as electronic communication or telehealth provided through a satellite location.

Social supports are important to the patient impacted by social determinants of health. The primary care physician may need to reach out to family or the community, while adhering to HIPAA regulations, to encourage the patient to continue to take advantage of the quality healthcare and to follow the care plan laid out by the physician.

Social determinants of health can significantly impact a patient’s well-being. Providing value-based care to such patients will require outreach and continued support on the part of the primary care physician.

Damien Neuman
November 14, 2018

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Study shows how persuasive design principles in primary care could improve data entry in EHRs

Accurate patient data is critical for the health of the patient as well as for record keeping and reporting for the primary care practice. Entering patient data can be time consuming and may not always be done in a timely manner. Even though electronic health records (EHRs) enable the primary care physician to enter data and update visit notes during the patient visit while continuing to stay focused on the patient interaction, many providers do not complete their notes right away.

Same day notes have been shown to be more accurate, but studies have also shown that only about half of clinicians seeing patients actually input those notes on the same day as the visit. A recent research study set out to determine how to encourage more primary care physicians to complete their EHR data entry on the patient visit day. The study objective incorporated the need to “find ways to influence clinician’s behaviors around data entry and data quality.”

In addition to the timing of the entry, the study found a need for encouraging EHR users to “enter a complete entry within the structured form, and encouraging error-free entries.” The study objective was to “to expose clinicians to persuasive design in order to modify their data-entry behaviors.”

Through a process of analysis and context definitions, the researchers “identified several persuasive design principles that could help change the data-entry behavior.” Some of the persuasive design elements included visuals such as a summary screen and badges “to encourage and normalize entering data on the same day.” In particular, the design incorporated a “same day badge” that was “programmed to display and reward the percentage of same-day entries.”

The researchers tested the persuasive design of the EHR with 53 users over a period of 16 weeks, including 8 weeks prior to the change and 8 weeks after. At the end of the post-change period, the team conducted an analysis and found that “the intervention increased the percentage of same-day entries by 10.3%.” Recognizing the limitations of their study, including the number of test subjects and the research timeframe, the researchers indicated that “Future work will involve exploring and evaluating the long-term impacts in greater detail as well as assessing iterative improvements to the design.”

Damien Neuman
November 12, 2018

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How primary care physicians could use EHRs for patient engagement in the future

Independent physicians use electronic health records (EHRs) to maintain accurate and timely patient medical records. Primary care providers can collaborate with specialty providers, making referrals and reviewing visit notes efficiently without waiting for faxes or returned phone calls. Primary care physicians also encourage their patients to view their own medical records and to communicate electronically through their portal, as they realize using an EHR for patient engagement can also be very effective.

However, a 2017 report published by the Government Accountability Office (GAO) explains that “relatively few of these patients accessed their records online, and patients typically did so in response to a medical visit.” The report specified that “health care providers that participated in HHS’s Medicare Electronic Health Record Incentive Program offered nearly 9 out of 10 patients the ability to access their health information online.”

Using an EHR for patient engagement can be effective in promoting communication and in encouraging patients to become more involved in their own plan of care. Primary care physicians can use EHRs to engage with their patients by discussing the challenges and the opportunities for the patient during the visit. Many patients actually prefer electronic communication, particularly millennials.

EHRs that offer patients the opportunity to communicate as well as to schedule appointments and pay their bills online will be more enticing to patients who prefer the convenience of electronic access. The key to communication through a patient portal is timely and accurate responses, of course. The primary care physician or a qualified member of the clinical staff must respond to the patient quickly to encourage patients to use the EHR more often.

The primary care physician can also use the EHR for patient engagement by proactively reaching out electronically. For example, the Elation Health Clinical EHR allows the provider to quickly identify patients who aren’t meeting goals based on custom care management protocols, Meaningful Use objectives, or specific document tags, and easily schedule a follow-up appointment to address any potential gaps in care.

Damien Neuman
November 5, 2018

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What is shared-decision making?

Part of the challenge in providing value-based, quality healthcare to patients is having those patients follow care instructions, fill their prescriptions, and properly follow the primary care physician’s directives for additional tests or treatment. Human nature is such that we like to have input into decisions that affect our future. When patients have a part in the medical decision-making process, they are more likely to become engaged in their own healthcare.

Shared-decision making is just that. The primary care physician and the patient collaborate to make those decisions that impact the patient, including determining which tests to undergo, deciding on an effective and sensible treatment plan, and determining which medications will work best for the patient, based on the patient’s lifestyle and willingness to follow up on those decisions. These decisions must, of course, be “based on clinical evidence that balances risks and expected outcomes with patient preferences and values,” as described by Health IT’s National Learning Consortium.

The Consortium has found that when patients participate in the shared decision process, they are more engaged and that results in patients:

  • learning about their health and understanding their health conditions
  • recognizing that a decision needs to be made and are informed about the options
  • understanding the pros and cons of different options
  • having the information and tools needed to evaluate their options
  • being better prepared to talk with their health care provider
  • collaborating with their health care team to make a decision right for them
  • being more likely to follow through on their decision

The Agency for Healthcare Research and Quality (AHRQ) offers the SHARE approach for the primary care physician to actively engage the patient in shared-decision making:

Step 1: Seek your patient’s participation.

Step 2: Help your patient explore and compare treatment options.

Step 3: Assess your patient’s values and preferences.

Step 4: Reach a decision with your patient.

Step 5: Evaluate your patient’s decision.

Electronic health records (EHRs) can assist in the shared-decision making process as well. Patient portals and secure electronic messaging allow the primary care physician and the patient to communicate securely, so the patient feels free to ask questions, to seek clarification, and to provide input on healthcare decisions.

Greg Miller
October 31, 2018

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Preventative care v. preventive care

When physicians discuss immunizations and screenings with patients, they may refer to them as preventative care or as preventive care. In reality, there is no difference in the two terms except for the spelling. Both terms have been around for many years, although the term preventative has often been seen as a degradation of preventive. Of course, independent physicians and preventive care (or preventative care) are linked together as primary care practices typically emphasize those services to their patients.

Both terms have been used since the 17th century, when independent physicians and preventive care appeared in print slightly earlier than the association with preventative medicine. By the 19th century, however, the term preventative was looked at as “unseemly.” John Russell Bartlett was adamant when writing in A Dictionary of Americanisms, published in 1848, that preventative was “A corruption sometimes met with for preventive both in England and America.”

As recently as 1964, a letter to the editor of the JAMA Journal asked, when referencing the story of a professor who would fail his students for using “preventative” in the title of his class on preventive medicine, “Is it possible that preventative has become acceptable or respectable because many people prefer it to preventive?” The editor responded that “most people prefer the shorter and slightly more venerable form of the word.”

Whether it is referred to as preventative care or preventive care, it is critical for healthcare outcomes. Independent physicians urge their patients to keep on track with screenings and immunizations that can prevent debilitating conditions and catastrophic illnesses. Primary care physicians know that blood pressure checks, tests for diabetes, and screenings for cancers can detect illnesses before they become major issues for the patient.

Most preventive services are covered under insurance plans, direct care plans, and Marketplace coverages. When these services are available to the patient at no additional cost, it makes sense to stay on schedule with the preventive – or preventative – measures to ensure quality patient outcomes.

Greg Miller
October 29, 2018

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