Background/Purpose:

The electronic medical record (EMR) promised greater efficiencies in clinical medicine. This goal may be met in part in an ICU, operating room, and other settings in which large amounts of data are exchanged in real time, and a patient medical history contributes little to work-flow. However, in outpatient management of chronic diseases, particularly in rheumatology, in which the patient history contributes importantly to diagnosis and management, the EMR has been associated with serious compromises of doctor-patient communication and inefficient time-management. Many physicians spend considerable periods entering and/or dictating information into an EMR after the patient has left the exam room, and not infrequently during evening hours. Some rheumatologists have suggested that the EMR results in seeing fewer patients per day, leading to a reduction in income despite up coding of visits using EMR documentation. One approach to this problem involves application of a simple principle seen in customers of airlines printing boarding passes and of supermarkets checking out groceries, by having patients complete an electronic self-report history questionnaire that can be uploaded directly into an EMR in a traditional history format, with review by a physician, using software termed “private medical history” (PMH).

Methods:

Patients enter medical history data on a structured self-report questionnaire, including all diagnoses, operations, illnesses, hospitalizations, allergies, family history, social history and demographic information, into PMH software. The data can be uploaded in a standard format into an EMR, although interaction with the EMR vendor is required to implement this feature. The PMH software also allows patients keep maintain the data at a password-protected, HIPAA compliant, secure PMH website, which can allow the patient to store the data for any health professional as a paper print out or PDF file, and, as more EMR organizations become compliant with the PMH system, to interact directly with any EMR. The patient web page allows the patient an option to indicate that each section of the history is correct or requires update(s) and/or correction(s).

Results:

Preliminary studies indicate at least 80% agreement of patient self-report medical history information with what is reported in the EMR in more than 80% of patients. Some patients require help from family and/or health professionals to provide an accurate history. Most patients appear at least as accurate or more accurate than health professionals. Use of the system saves about 15 minutes for the doctor per new patient.

Conclusion:

A large fraction of patients can enter much medical history information directly into an EMR and store the information to update and/or correct, and be available for any health professional or facility with any EMR for future visits. Rheumatologists who would like to implement such a system are encouraged to contact the authors of this abstract.

« Back to 2018 ACR/ARHP Annual Meeting

ACR Meeting Abstracts - https://acrabstracts.org/abstract/can-patients-enter-medical-history-data-by-self-report-directly-into-an-electronic-medical-record-emr-private-medical-history-pmh-software-for-physician-report-in-emr-format-and/