Will the H&P be replaced by technology? or “No, Virginia, there is no tricorder”

EDITOR’S NOTE: Dr. Erica Remer reported this story live during the Dec. 3 edition of Talk Ten Tuesday. The following is an edited transcript of her reporting.

A Medscape survey popped up in my email a few weeks ago. The title was, “Is Technology Replacing Patient History?” (https://www.medscape.com/viewarticle/921235) and it linked to an article by  David Warmflash, MD, entitled, “Are the History and Physical Coming to an End?” (https://www.medscape.com/viewarticle/917730).

The survey asked:

• How do you think technology is affecting the practice of medicine?
• Do you think technological advances will eventually make the patient history and physical obsolete?
• What percentage of diagnoses do you make based on history alone, and on history and physical together?

Apparently, it was folklore that always led me to assert that 85 percent of the time, if you ask the patient the right questions, listen to their answers, and do a good physical examination, you don’t need to do any studies to figure out what is wrong with the patient. The article quoted a study from the British Medical Journal from 1975 which found that the H&P alone was adequate for diagnosis 91 percent of the time.

This article introduced me to a new concept: multiomics. This word relates to the set of new “-omic” technologies, such as genomics, epigenomics, immunomics, proteomics, and metabolomics. The application of these multiomics to diagnosing and pinpointing the treatment of diseases is, indeed, revolutionary. But will the utilization of these advanced techniques coupled with next-generation imaging, and wearables’ data really replace the patient-provider interaction?

When the Centers for Medicare & Medicaid Services (CMS) started floating the concept of letting the provider decide how much history and physical is indicated for any individual encounter, my alarm bells started going off. My experience is that even excellent physicians don’t always do excellent documentation, even under the current mandated documentation requirements. Relaxation of documentation requisites is certainly not going to inspire bad clinicians to improve their documentation, either.

Is CMS making the appropriate adjustment to attain its goal of relieving provider burden? The logical action to me would be to reassess the presently mandatory PFSH components. The past medical history may shed light on today’s issue so make the requirement relevance. A review of medications may reveal side effects or prevent interactions. However, the fact that a patient smokes or drinks uses illicit drugs, or what they do for a living may not be necessary for every encounter. Family history could be significant in certain situations, but irrelevant and a waste of time in others. Clearly, a comprehensive review of systems is not necessary for every patient; make the requirement, “an appropriate ROS,” without mandating a number of points.

As per the final rule scheduled to snap into place in 2021, performing and documenting a “medically appropriate history and/or physical examination” in the outpatient office setting seems intuitively reasonable to me. The problem is, without some guidelines, this will be challenging to assure compliance. Will this leave room for interpretation for the auditor to deny levels of service because they don’t think the history or the physical was adequate? Additionally, will providers misunderstand the rule and generalize the guidelines across other places of service?

The reality of clinical practice is that, under some circumstances, an H&P is sometimes sufficient to make the diagnosis, sometimes multiomics would be enough, but most often a combination of history, physical, and data is optimal to take care of a patient. We need to use technology as a tool, not as a substitute for the patient-provider interaction. And then we need to document it so everyone else knows what we heard, saw, thought, and plan.