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.

Facebook
Twitter
LinkedIn

Erica Remer, MD, FACEP, CCDS, ACPA-C

Erica Remer, MD, FACEP, CCDS, ACPA-C has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

Related Stories

Key Takeaways from CHIACON 2025

Key Takeaways from CHIACON 2025

I had the pleasure of attending the annual California Health Information Conference in Long Beach, California, as an attendee and as a speaker, last week.

Read More

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

The Cost of Ignoring Risk Adjustment: How HCCs Impact Revenue & Compliance

The Cost of Ignoring Risk Adjustment: How HCCs Impact Revenue & Compliance

Stop revenue leakage and boost hospital performance by mastering risk adjustment and HCCs. This essential webcast with expert Cheryl Ericson, RN, MS, CCDS, CDIP, will reveal how inaccurate patient acuity documentation leads to lost reimbursements through penalties from poor quality scores. Learn the critical differences between HCCs and traditional CCs/MCCs, adapt your CDI workflows, and ensure accurate payments in Medicare Advantage and value-based care models. Perfect for HIM leaders, coders, and CDI professionals.  Don’t miss this chance to protect your hospital’s revenue and reputation!

May 29, 2025
I050825

Mastering ICD-10-CM Coding for Diabetes and it’s Complications: Avoiding Denials & Ensuring Compliance

Struggling with ICD-10-CM coding for diabetes and complications? This expert-led webcast clarifies complex combination codes, documentation gaps, and sequencing rules to reduce denials and ensure compliance. Dr. Angela Comfort will provide actionable strategies to accurately link diabetes to complications, improve provider documentation, and optimize reimbursement—helping coders, CDI specialists, and HIM leaders minimize audit risks and strengthen revenue integrity. Don’t miss this chance to master diabetes coding with real-world case studies, key takeaways, and live Q&A!

May 8, 2025
2025 Coding Clinic Webcast Series

2025 ICD-10-CM/PCS Coding Clinic Update Webcast Series

Uncover critical guidance. HIM coding expert, Kay Piper, RHIA, CDIP, CCS, provides an interactive review on important information in each of the AHA’s 2025 ICD-10-CM/PCS Quarterly Coding Clinics in easy-to-access on-demand webcasts, available shortly after each official publication.

April 14, 2025

Trending News

Featured Webcasts

The Two-Midnight Rule: New Challenges, Proven Strategies

The Two-Midnight Rule: New Challenges, Proven Strategies

RACmonitor is proud to welcome back Dr. Ronald Hirsch, one of his most requested webcasts. In this highly anticipated session, Dr. Hirsch will break down the complex Two Midnight Rule Medicare regulations, translating them into clear, actionable guidance. He’ll walk you through the basics of the rule, offer expert interpretation, and apply the rule to real-world clinical scenarios—so you leave with greater clarity, confidence, and the tools to ensure compliance.

June 19, 2025
Open Door Forum Webcast Series

Open Door Forum Webcast Series

Bring your questions and join the conversation during this open forum series, live every Wednesday at 10 a.m. EST from June 11–July 30. Hosted by Chuck Buck, these fast-paced 30-minute sessions connect you directly with top healthcare experts tackling today’s most urgent compliance and policy issues.

June 11, 2025
Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Substance abuse is everywhere. It’s a complicated diagnosis with wide-ranging implications well beyond acute care. The face of addiction continues to change so it’s important to remember not just the addict but the spectrum of extended victims and the other social determinants and legal ramifications. Join John K. Hall, MD, JD, MBA, FCLM, FRCPC, for a critical Q&A on navigating substance abuse in 2025.  Register today and be a part of the conversation!

July 16, 2025

Trending News

Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more

Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!

CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24