The Office Visit Revisited

A patient calls or emails me with a problem. I talk with them over the course of a few days, using whatever form of communication works best.  Eventually, they need to come to the office to be seen – either for something needing to be done in-person (examination, procedure, or lab test), or because of the advantages of face-to-face communication.  At the visit, I not only deal with one problem, but there are other issues needing to be addressed.  Finally, after the visit, follow-up on the problem continues until it is either resolved, or at least is not causing much trouble.

So how do I document that?

In the past I would’ve had a clear structure for the “office visit” and separate “encounters” for the documentation of the communication done outside of the office.  The latter would be done largely with narrative of the conversation, and some direct quotes from the patient.  The former, the “office visit” would include:

  • A re-telling of the story of the “chief complaint” and what’s been happening that caused this encounter to be necessary.
  • A sifting through other symptoms and past-problems to see if there is any information hidden there that may be useful.
  • A documentation of past problems (already in the record) to support the thought process documented later in the visit.
  • An overview of the physical exam, again to support the  decisions made as a result of the visit.
  • A discussion of my thoughts on what I think is going on.
  • A telling of my plan on how to deal with this.
  • A list of any advice given, tests ordered, medications changed, prescriptions written, and follow-up as the details of that plan.
  • A signature at the end, attesting to the validity of what is contained in the note.

But here’s the problem: it’s not real.  I don’t make all of my decisions based on the visit, and the patient’s story is not limited to what they tell me.  Details may be left out because they are forgotten, questions aren’t asked, or things just haven’t happened yet.  This signed and sealed unit of care, represented as a full story, actually represents only fragments of the story, of many stories actually, and only as a moment on the continuum of the patient’s care.

But there it stands, the office visit, the center of the patient’s medical record.  It is what my past life defines as “health care.”  But for me now, it is an anachronism: an old-fashioned idea that has nothing to do with my present reality.  My care is no longer episodic, so why should my records be?  I no longer need “visits” as units of commerce, and no longer need “problems” as the goods for which I am paid.  This took me quite a while to figure out, and has me making some radical (crazy?) changes to how I think about care.

1.  Stop Artificially Defining Units of Care from My Perspective

The “office visit” is a unit defined from the physician’s perspective.  This may actually undermine a clear thought process, though, fooling me into believing I’ve finished something that isn’t complete.  Instead of breaking care into a temporal unit, why not define it another way:

  1. The narrative – what is going on with the person.  The patient narrative goes over their lifetime, some of which happens in my office.  Narrative would best be a combination of patient input and my observations as a third-party.  My job is not necessarily to do the narration, but to guide it by asking questions and to prioritize that which I think is most salient.  Each “problem” may have its own narrative, but those lines often blur, as the chronic disease causes depression, and both the chronic disease and depression lead to fatigue and increased pain.  How do you divide those?  Do you need to?
  2. The investigation – both through my questions, examination, and through tests I order, I work to solve puzzles.  The patient wants me to make sense of confusing parts of their narrative, so I step in and investigate.  Tests are ordered for a reason, and exams are generally problem-driven.  One of the most important “tests” to do is to wait and see what happens.  Sometimes stories only become clear as they unfold, and it is my job to know when it’s best to do nothing other than wait and observe.
  3. Interventions – medications, lifestyle changes, education, and procedures are what most people think of when they define “health care.”  Yet these are entirely driven by the narrative and investigation.  They add to the narrative and often become part of the investigation, but they never stand alone.  Well, they shouldn’t stand alone, despite the fact that they are what doctors are largely paid for in this country.
  4. Destinations – what are our goals?  What is the goal of the patient in the bigger sense, and what are our goals for individual narratives?  The destination is the entire purpose of the doctor-patient interaction.  The patient doesn’t like their destination and I am called on to help them go somewhere else, or they just want to be sure they are not inadvertently going to a bad locale.

Can I do a record based on these categories?  If I do, would it end up as a crazy jumbled mess?

2.  Find Strings to Tie the Pieces Together

Each part of the record of care is tied together in different ways, with different things that they share with the other pieces of information or narrative.

  1. Diseases – these were referred to as “problems” in my past life, a euphemism if there ever was one, but part of each record is usually devoted toward the prevention, treatment, or management of disease.  Narrative, investigation, intervention, and destination could address these aspects of disease.
  2. Symptoms – these also (perhaps more appropriately) were listed as “problems” in my past life.  They are how health directly impacts the patient.  Symptoms may or may be related to a one or many diseases, or may be mysterious.
  3. Risks – These are sometimes determined by choices of the patient (smoking, drinking) or not (family history).  The reason we at all care about smoking or family history is the risk they confer.
  4. Events – Big events, such as heart attacks or motor vehicle accidents can result from or cause disease, but they are tied together in a temporal way.  In the same way, an office visit is a temporal way to tie together interactions with a patient on a given day.  (I didn’t say it’s entirely bad to consider visits as units; it’s just bad to only define them that way).
  5. Situation/Environment – What’s going on in the other areas?  Is the person getting a divorce?  Is it allergy season?  Is there a flu epidemic?
  6. Population factors – some narratives, investigations, interventions, and destinations can transcend a single patient.  My ability to see the population as a whole will help me to give better individual care.

Where does this lead?

What does a record in such a world look like?  I can’t say I’ve come to a clear idea, but there are some things I’ve started doing:

  1. Treating narrative as a separate entity – Whether communication happens via secure message, on the phone, or via email, narrative is narrative.  It is the fuel that propels good communication (my listening to it) and by which proper care is given.  Lumping narrative with the other areas tends to artificially categorize it.  The result is a separate documentation of narrative from exam, intervention, etc. in the record.
  2. Tying narrative and the other areas together using things they have in common. I have started using diseases, symptoms, risk factors,  and events as tags, tagging narrative, consults, lab results, medications, and anything else with these fathers (so I can see all conversations, examinations, lab tests, consults, hospitalizations, etc. related to a person’s diabetes, for example, or seeing all other parts related to a specific medication).
  3. Allowing free-flowing use of tags to give me different views of the same parts of the record. In general, the more perspectives one has when looking at something, the more accurate the picture.  This means tagging needs to be simple (perhaps automatic) and robust.  It also means that I need to be able to quickly get those views when I (or the patient) need them.
  4. Working with the patient to come up with a destination – an overall plan of what they expect to get out of my care.
  5. Going over the progress toward those destinations on a regular basis.
  6. Making all of this fully available to my patients. This assures the accuracy of the information and keeps it focused where it should be: on the person for whom this whole system is built.

Sounds crazy?  Sometimes I wonder.  But then I look at what my past life as a doctor involved, and what “care” was defined as, and I begin to grin.  That was crazy.  This is simply being myself, which, for once, doesn’t seem so crazy.

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind),where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player. He is a primary care physician.

13 replies »

  1. My mother is general practitioner in a small town, where people know each other very well and this helps her quite a lot to make good diagnose. When her patient describes some difficulties, she knows what he does, how active he is and so on and this makes a good deal of facts needed to know.

  2. Hi,

    Wonderful Post.I agree with this that communication between Patients and doctors are changed . For most physicians, the establishment of good relaionship with a patient is important. Some medical specialties, such as psychiatry and family medicine, emphasize the physician-patient relationship more than others.

  3. Massachusetts recently enacted a law requiring demonstration of Meaningful Use compliance a condition of physician licensure (minimally”).

    I’m not making that up.

    It doesn’t take effect on until 2014; it was slipped in at the last minute while no one was paying attention. Maybe they will repeal it, but we’ve heard rumors of this sort of push before. One of the more outlandish proposals was to make accepting Medicare patients per se a condition of physician licensure.

    Well, if you don’t bill for either Medicare or Medicaid, Meaningful Use and its attendant EHR transactional/encounter paradigm is irrelevant to you (like Dr. Rob now). Unless the pols force it on you down the road via licensure to prop up the federal HIT/HIE initiative.

    Bears vigilance.

  4. hi Rob,
    Thxs for this post. Like you, I have a direct-pay practice and do a lot of phone/email care, which I’m still trying to figure out how best to document. Agree that tags would be great!

    For myself, I’ve noticed that I really rely on a longer in-person visit to catalyze a longer, more thorough note that checks in on all active problems and summarizes the state of things. Not sure that an in-person visit needs to be linked to the mental process of doing a comprehensive review, but I do think periodic comprehensive reviews are important, so am hoping that eventually EHRs will get better at supporting clinician and patient in doing this.

  5. I believe our system withholds medical information from patients and holds all care hostage to force patients to come in to the office so we can get paid. I know that’s the world I used to live in. It’s hard to blame patients for not taking responsibility when they don’t have the tools to do so. I do know there will be a spectrum of people, ranging from those who spend lots of time in their records, to those who rarely go there. Some will want me to do all the work for them, but I will be in the position to politely refuse paternalism.

    Right now, the response is still kind of humorous, in that people really don’t believe that I mean what I say when I tell them that they can call or message me with questions. They seem to be waiting for me to take back the reins of control, but I don’t want them. I really want people doing what they can to make their care better. My job is to give tools to make that possible.

  6. The idea of having our information flow the way that our mind naturally works, makes complete sense. In the grand scheme, this is a minor technical challenge (better UI, effective tagging, inputs from social media/phone/email/in-person, etc…), but a major challenge of political will and orthodoxy. Like most good ideas, this one will take hold in time.

    Kudos for writing up the V.1 blueprint! =)

  7. Patient verses Doctor “responsibility” is a complex issue that, in my opinion, needs to be individualized. “One size never fits all” in medicine.

    While the trend is toward less paternalism, less dependency, less infantilizing patients, more co-decision making and more patient responsibility (all good!) not all patients are ready for this?

    One of our jobs is to help them all grow up. But some patients may never reach maturity in their lifetimes. A lot of it has to do with the patients upbringing, age, education level and socio-economic status (SES)

    Dr. Rick Lippin

  8. No question. I believe the record is their record, not mine. I want them to believe their health is their responsibility, not mine. I am a helper in this, and will enable them to do so in a way they couldn’t without information.

  9. I do agree that touch could be lost, although there is little of it in the standard office visit. I have noted that my patients are still afraid to call me and “bother me” with phone calls or emails. This doctor-centered view is hard to lose. I think once people are more comfortable with open communication that centers around them, they will be more open. I really think the main problem is that doctors stopped caring about the individual, and that not looking, listening, and touching are symptoms of that. My patients still find it hard to believe I’ll talk to them on the phone. Quality of interaction trumps quantity.

  10. I think you’re right that ways of communicating are changing rapidly, and therefore what “documentation” is is also changing. Do you also envision a way for patients to communicate and/or directly contribute information into their record?

  11. This is wonderful and just captures what I see as key to the future that I wrote about but offer so much more to my view. Thank you.

    “Does the patient leave with an Rx? Or do they leave with a continuum of care based on integration into the brand platform? ‘My physician is a great doctor but he is also doing more then caring for me, he hears me.’ ”

    “The Office Visit is Not a Drive By”

  12. Good ideas in post- But-

    The biggest three mistakes that physicians made in late 20th and early 21st century US Medicine are that doctors stopped 1) listening to patients, 2) looking at patients 3) touching patients.

    There are many reasons for why we abandoned these behaviors. But in my opinion we need to get back to these basics to some degree.

    Dr. Rick Lippin

  13. Great post, Rob. I have often wondered why I needed to “see” patients, when I could manage them remotely – it certainly is not because my patients wanted to come into the office. Unfortunately, as you mention, our system is still based on “doing things” that can be lumped into units of commerce. I am keeping my fingers crossed that payment reform will occur in such a way that episodic medical care moves towards true longitudinal healthcare.

    Regarding the record you mention, a forward thinking internist named Dr. Kim Dunn is also trying to work out exactly what you propose. She has been piloting the Your Doctor Program here in Houston for some time now as a way to incorporate patient centeredness, risk management, and care collaboration seamlessly into primary care through a new type of longitudinal care record. Here’s hoping the two of you are on the leading edge of a steady march towards more meaningful (and appropriate) healthcare.