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June 7, 2019

The Review of Systems, the Electronic Health Record, and Billing

Author Affiliations
  • 1Department of Pediatrics, University of Minnesota Medical School, Minneapolis
  • 2University of Minnesota Masonic Children’s Hospital, Minneapolis
  • 3Department of Surgery, University of Minnesota Medical School, Minneapolis
  • 4Institute for Health Informatics, University of Minnesota, Minneapolis
JAMA. 2019;322(2):115-116. doi:10.1001/jama.2019.5667

The practice of obtaining a broad and thorough assessment of a patient’s health status by conducting a review of systems (ROS) has been taught to medical trainees as an integral part of the history-taking process for decades. In 1995, the ROS was further codified as a required part of a complete medical history in the United States through documentation guidelines for clinical evaluation and management (E/M) by the Centers for Medicare & Medicaid Services (CMS).1 The architects of these guidelines created a framework for E/M reimbursement based on the premise that documentation could function as an accurate proxy for services rendered.

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    3 Comments for this article
    Review of Systems vs Chief Complaint
    Vincent Friedewald, M.D. | University of Texas Health Science Center - Houston
    There is only a fixed and limited amount of time for each patient engagement. Is that time better spent in in-depth, focused attention to the chief complaint, which is the key element for a correct diagnosis, or diminishing that part of the history to obtain a comprehensive ROS, which, as pointed out, can be easily obtained by patient self-reporting? I vote for spending the time on the C.C.
    ROS, EHR, Billing & the Devolution of Healthcare
    Stephen Strum, MD, FACP | Private Community Practice of Hematology/Oncology
    I speak as a physician with 51 years in the practice of medicine, and the perspective of a careful observer about the course of healthcare during this half-century period. Our profession has devolved from that of art & science to now predominantly a business. The prevention of human illness, and the resolution of what ails our patients have taken a distant back seat to physician or institution income. The vast majority of physicians have sold their soul to the company store.

    The irony of this is that we have made serious advances in medicine and
    technology, while patients, far too many, "orbit" in a revolving door of non-resolution of their medical problems. Instead of the computer helping resolve these problems, the computer is an accomplice to the financial abuse of the patient. Hendrickson, Melton, and Pitt diplomatically hit on this with observations that need the attention of a physician-based workshop to mend a system that is blatantly broken. Yes, we certainly have "less-personalized patient-clinician interactions and "bloated" notes with redundant information." I recently reviewed, page by page, 255 pages of one patient's medical records from a prominent center in Minnesota. I would estimate that 85% or 217 of those pages equate with a copy-paste maneuver. I have focused on consulting in the last 15 years of my medical career, and I see medical records from the USA, Canada, Europe, and Australia. The same problems exist globally.

    Hendrickson et al. state "professionalism and integrity should preclude misrepresentation in the medical record" and "it is inappropriate and counterproductive to allow a poor match between a clinician's judgment and institutionalized billing expectations." This is an understatement; it is far too polite. Physicians who acquiesce to so-called healthcare organizations or medical institutions and misrepresent the medical record due to financial incentives are spineless; instead of more accurate diagnoses through use of the computer, we disgrace the profession and abuse the patient. The ROS is just one facet of that abuse, which often starts with the chief complaint and ends with the disposition, but includes everything in-between. What I have seen in my lifetime is the death of a magnificent profession.
    Review of Systems - Waste of Time in its Current From
    Elliott Brender, MD, General Surgeon, FACS | Retired
    The review of systems (ROS) should not be a billing tool. In its electronic form it is a worthless waste of time. Its purpose is to address other systems that are not part of the history of present illness. It may point out co-morbidities e.g. the ROS for a patient presenting with abdominal pain in the RUQ presumed to be symptomatic gallstones who gets short of breath climbing less than one flight of stairs might be very important & point to further investigation before removing the patient's gallbladder. But this should have nothing to do with billing. Billing needs to be based on the complexity of the patient, not how many boxes are checked.