The patient-completed medical history facilitates the physician's interview by providing a comprehensive preliminary survey of the patient's medical history and problems in a systematic arrangement. This allows the physician to easily review the information and ensures they do not overlook important symptoms or past medical history due to time constraints, as the form draws their attention to significant details.

1. How to Stop Losing Money
Using Your EMR
John Bachman MD
Saunders Professor of Primary Care
Mayo Foundation

3. You are at the office
• A partner’s patient who has
hypertension comes to see you
because in the last ten days she has
noted that her blood pressure is
elevated from its baseline.
• Meds Lisinopril 20 mg daily
• BP 152/93

7. It collects for appraisal a large
and comprehensive body of information
about the patient’s medical history
at no expenditure of the physician’s time;
it facilitates interview by making available
to the physician a preliminary survey
of the patient’s total medical problems;
its data being systematically arranged,
are easier to review than those
of conventional medical histories,
and, by calling attention
to the patient’s symptoms
and significant items of past history,
it assures that their investigation
will not be overlooked because
the physician lacked time to elicit them

8. 1949-1980 “An era of
Questionnaires”
• Answer questions in form of paper and
physician got paper back
• Lahey Clinic Duke Medical Center
Kaiser
• Clinicians would write on output

9. Advantages
• Patients complete at their own pace
• Patients can do things at home
• Patients are prompts to remember
things
• The forms are inexpensive
• More data is retrieved
• Provides an outline

10. Disadvantages
• Patients do not complete forms
• Forms are hard to change
• Forms do not clarify symptoms
• Prime MD-3 minutes too long
• Mayo 1971 study
• Forms not personalized
• Too many forms that you need

11. General
• Mayo Clinic-PPI 13 page form 216
questions, 25 spaces
• ACOG on line 90 questions
• How many are enough?

12. Review of AFP in just one year
• 44 questionnaires (2 an issue)
• 4-37 questions
• CAGE-alcoholism
• Check list to Assessment areas for
Maintaining Healthy Geriatric Patients
• Depression scales
• Smoking Scales
• Lead

13. Patient Computer Dialogue
• Mayo Proceedings
in January 2003
• Solves input
problem into
computers
• Powerful Tool for
Quality
• Pilot: You want
passengers to use
electronic tickets

19. Recognizing Depression
7 26,671 Patient visits
6
5
4%
3
2
1
0
1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995
Implementation of Screening

20. 8 Time of a Routine Office Visit
S
O
7 A
6 8 P
E
5
4
3 Plan
2
1 Subj. 2
Obj. 2 Pat Ed
0
0.1
Traditional

21. 8 S
Future Time of a Routine Office Visit
O
7 A
6 P
E
5
4
Subj. Plan
3 Obj.
Pt. Ed
2
3
1 3 2 0.1 2
0
Software

22. Complete Physical Exam
35 S
35
O
30 A
P
25 E
20 17
Subj
nutes 15
15
Extra Time
10 7 8 7 Plan
Obj 5 Subj
5 Plan
Obj
0.1 0.1
0
OLD NEW

23. Going to the Web 2005-2012
• Primetime “Instant Medical History”
went to the web beside computers
• Published study of over 2500 online
visits at Mayo in 2010 at Mayo
Proceedings
• Integration of patient to the EMR
(Sage)

28. How many of you have a computer
do a history before seeing the
patient?

30. 2 Competitors

31. Doctors Good At
• Get them the information they can
put it together

32. Companies
• Primetime Practice “Instant Medical
History”
• Engine for almost all EMRs
• Competitors just do not last
• EMRs
• Incentives are to sell product
• Not necessarily add ons

35. How does it work?

40. OUTPUT IS GIVEN TO YOU
• Given to you on
paper
• Given to you in
electronic form like
into Word
• Directly into an
EMR

41. ADVANTAGES
Collects more
data then a
clinician and
organizes it
into a readable
form

44. Patient is better organized
Patients can do this

45. Patient collects information
that the clinician misses
• 40% of time
provided useful
information not
typically elicited
• Essential
Questions missed
• Pilot’s Checklist

46. How dangerous is health care?
Note: both dimensions are logarithmic scales
DANGEROUS REGULATED ULTRA-SAFE
(>1/1000) (<1/100K)
Health
Care Driving
10,000
Deaths per year
1,000
Scheduled
100 Chartered Airlines
Flights
Mountain European
Climbing Railroads
10
Bungee Manufacturing Nuclear
Jumping Power
10 10,000 100,000 1,000,000 10,000,000
Number of encounters per death

48. Socially Sensitive

49. Highly Adaptable
SARS

52. Others
• Patient controls interview-length of
time
• Doctor only deals with positives
• Research
• Multimedia
• High patient acceptance
• Scales

53. Scales
• Zung Depression
• Rahe Stress Scale
• Urology Scales
• Wast
• Conners
• Anxiety
• Pain impairment
• Patient Education Needs

56. Tough Diagnosis

57. Jane Doe
Chief Complaint Sore throat
VS stable
Sore throat 3 days duration

60. Lets look at history
80/20 Rule
20% of your questions get you 80% of
the content
Negatives are time intensive

61. Mining-Topsoil sand it is easy
Open ended questions
Listening 2 minutes

62. What are the results of
All this labor

63. It is like Mining
Yes/No questioning-tailings

64. You can use a machine to
Do the hard time consuming
Work

65. You are in control
You will trust the work done
Check out a few things

68. Benefits of Patient-Delivered Medical
History Data
• See more patients each day
• Reduce dictation and data entry time
• Cut transcription costs in half
• Populate EHR data fields automatically
• Support appropriate billing levels
• Enhance patient communication and satisfaction
• If over Web, option to enable triage: assess urgency,
lab/X-ray in advance of encounter, schedule for
appropriate amount of time, recommend self-care, etc.
• Patients are most incented and cheapest resource

69. Several Studies
• Acceptance has been documented in
ethnic18 diverse groups, rural
practices19, in prenatal visits20,
patients seeking a urologist help21,
adolescents22, sports examinations23,
and well child visits24. Reliability has
been assessed between personal
interviews for gynecologic patients25,
preoperative patients26, and general
practice27-29.

70. E mail consultation
I had surgery on June 11th, things went pretty well as far as the surgery went. I did feel pretty awfull for the first 2 weeks and the day I left the hospital my
incision broke open---I had to pack it for 3 weeks then it was restitched and healed well.
I have to admit, the first couple of weeks I was really beginning to wonder if I had done the right thing but my mind is slowly changing. It is interesting to
feel myself slowly turn my priorities away from eating. It is consistently amazing to realize how much focus there is on food, in society and in my life
specifically. Jim and I always have a ton of company, from friends to family and you know, company centers around food!!
It is an amazing feeling to be full so quickly---I am still not used to that feeling. I do have my fears about not getting enough protein in, I seem to be having a
problem eating meats but I am not to regular foods yet and I am still trying to tell myself to slow down, that is such a hard habit to break! I can't really
eat sweets, so far anything too sweet just makes me sick. The adjustment of not drinking while eating is difficult too, but getting easier. The milk
drinking is getting easier too.
I am so grateful for the year prior to the surgery---I know it was a long time and it was making me spitting mad at the time but................the group sessions
were such and asset to me ---I learned so much, I developed actual habits and restrictions in that year. I had pretty much given up sweets and over
eating and I think that has been a springboard for me with my diet now. I went to group every week with few exceptions. I learned so much about
myself, others, and eating disorders. I gained an insight that so diet could have ever brought to light. I learned to quit beating myself up, to recognize
weaknesses and avoid them. I learned and practiced the importance of activity. The importance of "self-talk" was emphasized and I used it as a tool
every day---especially on the bad days. I learned that it was never too late and that being over weight was not a sentence, that it was overcomable but
that the road to overcoming was a difficult one and that I needed help in changing from the well trodden path to a new one. I am now acutely aware of
emotional eating, but I have no choice in the matter, I simply can not indulge---it is so wonderful. I ended up losing 50 pounds in year that I went to
group and I am very glad for that little boost. I had a fantastic group leader, I really lucked out! Not for sure how much more I have lost but I know the
total is well over 100 pounds. and yes..............I feel so much better. I can walk up the back of St. Marys Hill without even getting out of breath. I am
still riding bike and of course riding horse. In fact, Jim and I are going to Wyoming in September for our 20th anniversary---we are taking our horses
out to the Big Horns riding for a week---I am so excited--this has been a lifelong dream for me and now my horse has 100+ less pounds to lug. Let me
tell you, riding is so much more of a joy for me, it is like starting all over.
Karie is doing well, still in PA with Jason, they were home for 2 weeks this month and we really like him, he is very sweet and seems totally devoted to
Karie---while I don't care for his tatoos,(its a mom thing)he really is great. He had a great time in Minnesota---so maybe the might move back here.
Justin graduated and Jim and I are really empty nesting it---Justin is working in the cities and staying with my niece--he plans to attend RCTC winter
quarter.
I am still going to school, I completed my Associates Degree last spring and I only have 22 credits left for my Bachelors.
I do so hope all is well with you, I think of you and your family often.
I want to thank you again Michelle for all of your years of care and concern, but most of all for directing me to this surgery and the journey that brought me
to it.

71. Omissions
• What Pharmacy?
• What do you want from me?
• What meds are you on
• Are you allergic to anything?

72. Primary Care Online

73. Vendor
• AAFP Approved
• Other users: Mysis
and Planned
Parenthood
• Online Visits
• Structured Histories

83. Missing Features
• Spanish
• Place for free text
• Place for meds and allergies
• Place for vitals
• Credit Card

87. Exchange Data
You do not need to be seen
In Reality Why it Could Work
EVIDENCE BASED
PROTOCOLS

88. Results of
patient
symptom
assessment

89. c

90. Which would you want?
• Call • Go Online
• Nursing time for • Clinician uses set
protocol protocol
• Clinician time to say • Clinician checks
ok prevention
• Appointment desk • Instructions that are
written
• Nurse faxes
prescription • Prescription faxed
automatically
• Verbal instructions
• Time in minutes
• Time in hours
• MMSI $35 charge - margin
• Clinic loses money better then an exam

91. Save Time - Go Online
PCOL

92. Our First Online Consultation

95. Patient was also scheduled for a mammogram

96. Billing
• Accountants high margin 35 dollars
• (Credit Cards) We went through
billing
• Went very smoothly

97. Totals 2 years
Largest Study Reported
• Total Registrations- 4282
• 7% primary family member
• Linked to 12%
• Online Consultations- 2531
• Total Consults Billed- 1159

98. What was the most common
online complaint ???

99. 293 different conditions were found

100. Who did the consultation???

101. What else did we learn?
71% were women
Youngest 4 days, oldest 86

103. 8-12

104. Prevent Visits to Office
• 40% of the time saved a visit
• 12.8% Come in
• 16% Protocols
• 11% of the time handled by “on call”

105. Pictures
• 49 pictures were sent in
• 2% of our practice
• Diaper rash
• Bites
• Contact dermatitis
• Prescription refills

106. What are the steps
• Vendor
• How will you get input?
• In lobby? In office room?
• From the web
• With EMR
• Portal??
• How to get into your system?

107. It collects for appraisal a large
and comprehensive body of information
about the patient’s medical history
at no expenditure of the physician’s time;
it facilitates interview by making available
to the physician a preliminary survey
of the patient’s total medical problems;
its data being systematically arranged,
are easier to review than those
of conventional medical histories,
and, by calling attention
to the patient’s symptoms
and significant items of past history,
it assures that their investigation
will not be overlooked because
the physician lacked time to elicit them