Richard Rathe, MD

Associate Professor of Family Medicine and Medical Informatician

The Rational HPI Project

The quickHPI web app is now available for general use!

This site presents a rational approach to the History of Present Illness and software called quickHPI. The purpose of quickHPI is threefold: 1) Provide a practical tool for clinicians; 2) Create a functional expression of the ideas presented here; and 3) Offer a self-directed learning tool for students and residents.

After working with a major EMR product for the past five years one thing has become abundantly clear to me…

IF the medical history is recorded via point-and-click forms, that information should not be obfuscated by “filler” text for the sake of generating a pseudo-narrative note.

QuickHPI was inspired by the well-known problems with forms-based data entry tools in the current generation of electronic medical records (EMRs). I will update the program periodically to reflect qualitative and quantitative evidence when available. (The medical literature is very thin in this regard!) I am also creating several native EMR tools based on this model. These cannot be released on a public website due to our contract with the vendor (Epic). Feel free to contact me with questions, comments, potential collaboration ideas, and constructive criticism: rrathe at ufl dot edu

Below I’ve listed the major issues addressed by a more Rational History of Present Illness

  1. Striking a Balance Between Clicking and Typing – Many HPI forms have too much specificity for use in primary care. They tend to have fields of buttons where a few typed words would be faster and more precise. quickHPI avoids this trap by providing text fields where buttons just get in the way.
  2. Platform Independence and Best Practices – With the widespread adoption of EMRs, the HPI has gone underground. Each proprietary system has its own set of templates that are not generally accessible for open review and discussion. This inhibits collaboration, quality improvement and research. It is no wonder my initial literature review yielded very little useful guidance for this project. QuickHPI is open source and available to anyone with a web browser. Based on input from a growing number of users, quickHPI will develop into a working consensus statement of best practices for clinical documentation.
  3. Problem-Oriented Charting – Each quickHPI session generates an HPI for a single problem. If there are two or more problems you may go through the process as many times as needed. You should avoid duplication as much as possible. The text generated is compatible with SOAP, APSO, H&P, and other problem-oriented note formats.
  4. Drawing a Bright Line Between Associated Symptoms and the Review of Systems  – Healthcare in the US is all about rules. This includes documentation required for billing. From a physician’s perspective these rules are rather arcane and the stakes are high. One casualty has been the outpatient note. In order for coders and auditors to efficiently review our notes, symptoms must be put into categories and certain key phrases must be present. Otherwise we run the risk of not being paid for our effort. A sad situation, but there it is. To a coder (and an EMR) a symptom is a symptom is a symptom, regardless of its clinical significance. This has led to the bad practice of including non-relevant symptoms in the HPI. Associated Symptoms (positive or negative) should be pertinent to the problem under discussion. The Review of Systems is just a series of questions without context.
  5. Format Notes to Facilitate Visual Scanning and Rapid Assimilation of Information – The phenomenon of Note Bloat is becoming a significant problem in healthcare. EMRs make it easy to build lengthy notes with a paucity of useful information (low signal to noise). Synthesized text may actually obscure the key findings! Even worse are the errors introduced when information is repeatedly copied (garbage in, garbage out). QuickHPI generates notes in a structured format that minimizes the amount of non-informative text. This is referred to as the Least Ink Principal

    The best clinical documentation is that which gives to the reader the greatest amount of information in the shortest time with the fewest pixels.

    Paraphrased from Edward R. Tufte
    The Visual Display of Quantitative Information