Episode 16:Patients Empowered: Improving Accuracy Through Co-Authorship

Episode Transcript

CJ: Hey, Welcome everybody to another episode of Compliance Conversations, I’m CJ Wolf, Healthicity’s Sr. Compliance Executive. Today we have a wonderful guest, Mike Warner, who has a really interesting background, and he’s doing some really interesting work. I really enjoyed talking to him before we scheduled the podcast, and I think you’re really going to enjoy this topic. Welcome, Mike.

Mike: Thank you. CJ. Good to be with you today.

CJ: Appreciate your time, and what we usually do with our guests is we ask them to just take a moment or two and tell us a little bit about yourself, professionally, how you got started. You have a unique background as a clinician who’s also jumped into the world of coding and auditing, and patients’ rights, and those sorts of things. So, if you wouldn’t mind just taking a moment, just tell us a little bit about your professional experience.

Mike: Sure, I’m a Osteopathic physician, board certified in family medicine, and also neuro-musculoskeletal medicine. I’ve practiced for nearly two decades in the Johnstown, PA area. Specifically, in the little town of Ebensburg which has 3,000 people. Most of that was with my physician wife Margaret. Just a couple years ago I made the switch from clinical practice to heading a nonprofit that promotes patients’ rights, particularly to access and a minimum health record.

CJ: Yeah, that’s kind of what I wanted to talk about more today. It’s a really fascinating subject, I mean, HIPAA was past over 20 years ago. A lot of people know about, I think the lay person at least, and patients know, and are getting to the point where they know “You know, Dr.’s, Hospitals are suppose to keep my medical record and those types of things private and secure”, but what you’re talking about, and we’ll jump into it here, is you know, patients have always had the right to amend and access their medical record, I think more patients are becoming aware of that, but you’ve really come up on a really unique aspect of that, which is, you know “can patients…”, and a lot of our audience that will be listening are coders as well, so they understand things like, in the medical record, a history, a physical, and medical decision making. But you have a really interesting project underway about patients co-authoring the medical record, and when people here that, I think, at least compliance folks they think “Wait, patients can’t co-author a medical record.” Tell us, Can they?

Mike: Yeah, well I’m just seeing where it comes from. From a Federal Guideline we’re told that you know, a medical assistant, or somebody of that nature in the office, can collect an HTI and patch down their social history, and that implies, you know, it’s up to the physician to sit down there and ask questions. But what’s really interesting is that through HIPAA, particularly through the privacy rule, the patient has the right to amend the record, and so, what we did, particularly in research around this time last year, that rather than have person give written authorization to amend the record, and then the provider take up to 30 days to decide weather your going to accept it or reject it. We immediately accepted it, and that impowered us through the HIPAA privacy law, for our staff to populate the medical with exactly what the patient said, the patient’s words.

CJ: Interesting. So, can you give us an example? What are they allowed to put in there, and what aren’t they allowed to put in there, so to speak.

Mike: As far as the patient?

CJ: Yeah, the patient. So, you’re talking about the patients right to amend their medical record, and kind of co-author the history a little bit. What kind of history can they directly put in, and how does that work mechanically? You know, in the flow of a patient encounter?

Mike: Right, right. Well up until this point there are probably a lot of clinician out there, and staff members listening, “Oh my god, the persons going to come in with like 50 pages of information, how could I possibly get through that?”. So, what we did, we came up with what we call a pre-history, which is just a replica of the history from 1995 and 1997 ENM Guidelines from CMS.

CJ: Okay.

Mike: So basically, Chief complaint, HTI, going all the way through from severity to modifying factors, you know what makes it better or worse, going through the history of present illness, status, and then going through past family social history. And because these items, this data has already been defined and structured by the government, we said why not allow, why not encourage the patients to deliver the information exactly in that defined structure. So what happens is, when you look at this information from the patient, you know initially you’re like “wow, this is going to be all over the place…” but, if the person is answering modifying factors what makes it better or worse, severity, how bad is it on a scale, what’s it feel like, going down the whole list, you know magically you walk into the room as a clinician and rather than starting off with saying “Hey, what brings you into the Dr.’s office today” which is such an open ended question, sometimes the person might respond back “Uh, because you had me get an MRI last week because I had problems with my back.” And their like “Oh, yeah.” What a difference the clinician is, from an attorney who’s prepared to go into court, who knows something about the person. So, this allowed like a quick download of the patient information, in a case already populated in the record so that the clinician can take off. Now the way we did it, we actually had a paper form, and so the patient submitted it and it had the legal stuff on there, saying this is submitted as part of the privacy rule to amend my record as a written notification. And the staff member would take that, they would scan it into the computer as a document, and then they would take the individual entries, which are all structured, so modifying factors and location and everything else, and type it in. It would take the staff member about 10 minutes to do this, because we did our research study and we did it over 250 people. And they would put it in there, and bingo, what I would do, is I’d walk into the room and I’d greet the person, “Hey CJ, how you are doing?” and I’d be able to sit down, and I’d say okay, let me take a moment to see what you wrote here. And it would take me about 30 seconds to read through what the person wrote, and then I’d be able to say “Wow.”, and I could reaffirm “You’re telling me, this, this, and this are going on?”, and then I could ask deeper questions, and the put those in, and then go to a pertinent exam, and then go to medical decision making, which because the time saving and the efficiency of information, readily transforms into shared decision making with the provider and the patient.

CJ: Yeah, and what I really liked about your approach, and I don’t know if our listeners picked up on this, is, you were very thoughtful, you and your group, were very thoughtful in the way you went about this, and you actually did it as a structured research project, you went to an IRB, which is an internal review board, to make sure it’s approved, like all research is done. And then you actually published the results. Did any of this make a difference, so kind of what you just explained I think is really fascinating, and then you measured the results, what did you find?

Mike: It was a game changer, an absolutely game changer. I can go back to the IRB experience, which was very unique, because people said this is unusual. No ones going to do this, no ones going to purchase it. They, and then even when I got everything all done and submitted it to publication. I went through the same rounds with the editorial board of the journal. Where they’re like, you know, I practically had to go through all the legal stuff and then show them. Look, what we do is measure two things, we measured the patient experience and we measured the provider and staff experience. For the most part in the paper we talked about the patient experience.

CJ: Okay.

Mike: So, what we did is, we sent out a letter sized envelope to all of our patients who are on my family medicine schedule, one week in advance. So that was the entry, so if you were on my schedule, bingo, one week in advance we sent you that letter. And then it had the prehistory, and also an invitation saying “Hey, fill this out.” It also had a pre-survey questionnaire, you know, for experience. And our only, what’s really interesting about this study, is that our only indication our person was in the study was when they showed up at their visit, they handed over the prehistory. That was our only indication, we had no advanced warning, and we kept a 15-minute schedule throughout the whole period of time of research.

CJ: Wow.
Mike: And what was really neat about it is, is that, it made the visit so efficient, that at the end of the visit, each patient was given a copy of the encounter note, and a post-survey, meaning that the moment the face to face was done, the visit was completely done, I signed off on everything, there was no finishing charts later that day.

CJ: Okay, and you said the patients received the full note, their history, part of which they provided, but also the exam and decision making, is that right?

Mike: All three key components, History, exam, medical decision making. And then the, the survey asks things such as “How satisfied are you as a patient in this office?”, our post gave us a 97%, which is, you know, just beautiful. Seeing the prehistory form made me feel more empowered in my healthcare, that one did really well too. As a matter a fact, our T value was less than .001, and for people in research, anything less than .05 is statistically significant. So that just buried it. Also, down low at that number was “Appreciated being given the chance to co-author my medical record” and also “I feel I was better heard and understood by having submitted a pre-history.” And you can imagine, for most patients it is a paradigm shift. Their use to going on their portal and seeing their medical problem list, their allergy list, their med list, and some results, but to really go in and see the words of what happened when they expressed their story and what finally got documented. They had the chance to do this and they were able to recognize what happened, partially because they were the co-author.

CJ: Yeah. Well as you’re talking Mike, I think, and I don’t know if your research showed any of this, but I’m just kind of, my minds going, you know, older patients, maybe not so much, but I think a lot of younger patients want to be more involved in their care. I’m obviously painting in broad strokes here, there’s always going to be exceptions, but is that something, like I think, you’re talking about the engagement that the patient felt, and they felt empowered in their care, I think these younger generations will kind of catch onto that. Did your research deal with that at all, or do you have thoughts about that?

Mike: Yeah, it sure did. Okay, so here’s what’s cool. We had a, let me address a little thing. We have 64% participation rate, which is pretty crazy.

CJ: I was going to say, “that’s great, isn’t it?”.

Mike: 60% of the participants were male. We were told by committees and stuff that men don’t care about their healthcare, they’re not going to participate. 60% were male, now I don’t think that means that in this research project men care more about their healthcare than women, I think what it did is it just more accurately reflected the physicians schedule. You know what I mean?

CJ: Yeah.

Mike: If I would have done this, this is western Pennsylvania, so if I would have done this during buck season there wouldn’t have been many males in the study.

CJ: Exactly.

Mike: And then our other thing was, our average was 66, but our range went from age 14 and 94. Statistically there was no difference in age group for participation. That’s another thing we hear from the IRB, they say well you know, people that are 30, or 20, they’ll participate, but the older people won’t. We saw it right across. Now, we also encouraged people to enlist the help of a family member, a friend, a caregiver, to complete the form, rather than a rapid fire in the office, like go over this. And there were many cases where this happened, as a matter of fact our two oldest patients in the study, the oldest, female, 94, severe dementia, her granddaughter who is also the caregiver and authorized personal representative completed the form. The second oldest, is a retired nurse, and she’s blind. So she actually had the caregiver tell her the questions, she dictated them back to her, she spelled it out, and then when I went to her house call on her, the pre-history is all done, isn’t that neat?

CJ: That’s neat.

Mike: And the two 14-year old’s that we had in the study, both of them completed their own pre-history. And it was really cool, because the parents, you know, I was wondering would the parents do it. The parents both sat back, and it was a neat experience to watch the parent watch their child to engage at that level.

CJ: Right, that’s real, that is so interesting. So, you said how many total patients were there, in the study.

Mike: Two Sixty Three.

CJ: Two Sixty Three, that’s great. So, tell me a little bit more about, were you the only participating physician, or were there other practices involved, is this something that can be tried again in other offices, tell me a little bit about the breadth of involvement.

Mike: Well for this particular study, it was all of me. What we’re planning on doing this Sept. / Oct. 2018 in the Johnstown PA area region, is having a 8 week multimedia campaign, billboards, tv ads, radio, that kind of stuff, newspaper. To encourage patients to participate, and our nonprofit patient advocacy initiatives is going to do our best to work with the healthcare systems, and local Dr.’s and staff members, to know how they can accept this. Yeah accept it. You don’t have to sit there and say, “Why are you here today, what’s your chief complaint?”, the patient can give it all to you and you can move forward with it. So, I’m hoping that this is going to be a regional testament that would then be saleable that it might work out more nationwide. The other thing we’re doing is, we’ve moved away, I mean we also have the paper form on our website, which by the way, everything on the website is free.

CJ: So tell us the website, what’s the website address?

Mike: It’s called patientadvocacyinitiatives.org you can also shortcut directly to the electronic pre-history by doing prehx.com. p r e h x .com.

CJ: So prehx.com is kind of the shortcut, that’s really really, I think, good information.

Mike: That’s the electronic form.

CJ: Okay, that’s the electronic form, and the website is again, patientadvocacyinitiatives.org, right? Did I say it right?

Mike: Yup, patientadvocacyinitiatives.org, and when you go on that over on the left-hand column you’ll see where there’s paper and electronic versions for pre history as well as sample forms. We also have an audio book that’s free, and we also have a bunch of you tube videos that are instructional for it. So we’re hoping that, as we conduct this regional experiment, that all these support things that we have there at the non-profit are going to help it go through. Because, if somebody reads this, and goes back to their provider tomorrow and says, “Hey I heard about this thing where patients can do their history.” There’s a good chance the Dr. will fall over. It just sounds like it’s going to bust things apart.

CJ: Exactly.

Mike: But it’s actually, let the patient do the prep time, let them participate, it works out really smooth.

CJ: I was just thinking, myself, as a patient, I would love that, I would appreciate being involved. And I know not every patient is that way, but I think more and more patients today, they’re trying to read about their condition on the internet and this and that. And I think that the involvement can really improve patient satisfaction as your study demonstrated. You mentioned that most of the study kind of focused on the patient experience, but I think you said, a little bit of it also on the physician experience. Any data there that you’d like to share? It sounds like maybe the encounters went more smoothly or quicker? Or what other findings from the physician’s side.

Mike: Well we did add a burden to the staff in the fact that they would need to work with the acceptance of the pre-history. That’s something we’re asking staff members to help you.

CJ: Sure.

Mike: Now one of the first things that came out from the staff surveys, which we did at the beginning, and then end, and then weekly, is that this should all be electronic. I mean, why is it that the patients pulling up his pre-history and the staff member has to sit there and type all this in. Which was a great epiphany, because I would say, “Why have we been expecting the provider to do it all these years?”.

CJ: Good point.

Mike: And I’m not trying to say, you know, my times more valuable, and all this kind of stuff. However, we want everyone to learn to talk to the licenser.

CJ: Exactly.

Mike: And I agree, that this would be a great thing for, if we can make this regional project work, and we’re trying to come up with a new pre-history intake form that is going to be, hopefully, plugging really nice, so that any EHR that wants to hook on, can just hook on and take the download. And that way, it can either be patient initiated, and the staff member can say okay and push the download button, so that it takes everybody out of the loop.

CJ: Yeah.

Mike: And that way, the person that greets you at the office can spend time greeting you and figuring out what you need and help you with the next appointment and all that stuff, they don’t need to worry about this mumbo jumbo. But also, at the same time, for the provider, it can auto populate.

CJ: That was going to be my next question and you kind of anticipated me on my next question there on EHR with more and more encounters kind of going that route. That would be a really neat idea, to see, can patients do a lot of this ahead of time electronically, it automatically populates there for the physician or clinician to review. Do you foresee any hiccups with that, or any kind of hurdles, with applying the same concept with the paper prehistory form in an electronic world?

Mike: You know, what’s interesting, Apple for example, has a whole bunch of vetting things on patient generated data. A lot of their concerns are over intellectual property, such as, if you open up a website, like Facebook or something, am I going to go to the movies and with my cellphone and take 2 minutes worth of the new Star Wars movie and then put it on my Facebook page, and that’s a copyright infringement.

CJ: Right.

Mike: You know, the cool thing about patient information, the person telling you how they feel, and what’s going on, the status of their chronic condition, their telling you about their diabetes, maybe their sugar, and how their feet are doing. If they were able to exercise, how they adhere to their meds or if they had side effects. You know, they work it straight back to their patient story, and what’s really kind of endearing, Dr. Larry Reed just passed away last June, and he was the physician the professor in the mid 6’'s who found medical records to be in disarray, and came up with the SOAP Note, I remember S is for seductive. So really, by allowing the patient to tell their story, we’re really kind of digging deeper into the patients’ subjective story. And I think we were for a period of time, we saw this anecdotal, and now we’re saying “wow, there’s good information.” Goes back to dr. William Moser, the whole thing of listen to the patient, he’s telling you the diagnosis.

CJ: Yeah.

Mike: So, it’s funny how things kind of come around. So, like you were saying before, it’s like a paradigm shift, where patient and providers are kind of looking at in a little bit of a different way.

CJ: Sure, yeah. Well mike we’re coming a little bit to the end of our time, but I wanted to kind of ask you kind of, one last question about your nonprofit organization, you mentioned to me before how it’s really focused on patients’ rights and access to amend. Can you tell us a little bit more about the organization and what your kind of mission and goals are for it?

Mike: Well our immediate goals, particularly with this upcoming project, just because we do a prehistory challenge in sept / oct in the Johnstown area doesn’t mean that other people can’t participate, I’ll gladly look for that. Easiest way to get ahold of me is through any of the YouTube videos, just ping and put a message in there. But our goals are to be to facilitate patient to medical provider information and improve medical records documentation and content integrity. And what I found in my own life, as a patient and caregiver to my family, I mean we’ve experienced death of a kidney donor to one of my family members, we’ve had a whole bunch of stuff happen, is that when we improve the documentation of the medical record, magically our outcomes, our treatment, and our care all improved. Wouldn’t that be great if that happened to everyone?

CJ: What a great mission. That’s a great story. So, in this 8-week campaign you said is going to be around Sept / Oct, folks should go to your website to learn more. Mike you mentioned that they need to contact you through, I guess you’ve got the YouTube videos on your website and they can connect with you that way. Listeners can always email me as well, and if Mikes okay with it I can sure that information with you and connect with people as well. I’m kind of interested, on your website, you told me the title of the article where you published this research was Use of patient authored prehistory to improve patient experiences and accommodate federal law, which journal was that in? If people wanted to read that article, or find that research, what’s the best way to go about doing that?

Mike: This is in the JAOA, Journal of American Osteopathic Association, from Feb. 2017, but if you start putting patient authored prehistory you’re going to start finding it. And also, by the way, on YouTube, we have a series of 5 little shows, called the patient advocacy show, and episode 1 is inaccurate medical records., but in that series we talk about the plight of the patient, the plight of the provider, and some solutions where the patients can get involved. It’s about responsible patients and responsive providers. And on there we mention a lot of these things like these articles.

CJ: Great Mike, thank you so much. This is a fascinating topic I think, I’d love to learn more about it myself, maybe we’d have you come back again, maybe in the Fall after this campaign we could learn a little bit more about how successful that was. I really appreciated your insights and your unique approach to a very important topic of these patients being involved of their documentation, how it helps their experience, how it helps the physician experiences. Just really appreciate you sharing with us today.

Mike: CJ thank you so much, as a physician, but also as a coder, oh boy this is really a fun project that can really help a lot of people, so I really hope it helps your audience.

CJ: Yeah, and I hope it will as well, I apricate you sharing and giving us the opportunity to share this really unique idea, so, thank you all for listening to this episode, and until we meet again, happy compliance.