Replacing Review of Systems to Improve Healthcare Delivery: A Functional Medicine Commentary

For decades, efforts to reform the delivery of health care in the United States have been evolving, with a growing interest in maximizing the value of healthcare services.¹ Most recently, the value of the traditional medical practice of collecting a review of systems (ROS) has been questioned. The review of systems was in part developed for reimbursement purposes as a component of the medical history-taking process by the Centers for Medicare & Medicaid Services (CMS). Until last year, clinicians were reimbursed at a higher level by CMS if visits included an ROS with inquiries about symptoms from at least 10 of 14 organ systems.² These financial incentives linked tradition-based care with reimbursement-based care.² However, on January 1, 2021, the ROS as a basis for reimbursement was replaced by CMS in favor of the complexity of the medical decision-making or total clinician time spent.²

This topic was explored in a viewpoint published in JAMA on September 30, 2022. In it, Barry et al explain that although the ROS is meant to improve care, the ROS process is not only time-consuming but, by eliciting minor issues that do not concern the patient, time is lost to address the patient’s primary concerns and health problems.² The authors note that this type of screening can also unintentionally lead to costly or potentially harmful workups of nonproblematic symptoms.²

The practice of obtaining an assessment of a patient’s health status by conducting an ROS has been an integral part of the standard history-taking process for years,³ and although CMS no longer accepts an ROS for reimbursement, some medical practices (even 18 months after the regulation change) continue to provide patients with ROS questionnaires.² Given that there is only a limited amount of time for clinicians to engage with each patient, it begs the question of how that time might be better spent.²

Barry et al ask the critical question: How should medical practices “de-adopt” the ROS, and what should replace it to improve care?² The authors suggest moving toward more evidence-based primary care; time saved could be spent on the delivery of proven preventive services like behavioral counseling and shared decision-making to ensure that patient preferences and the best evidence are incorporated into clinical decisions.²

“The Institute for Functional Medicine is pleased to contribute to the advancement of the effectiveness and value of the medical history-taking process. While useful for organizing patient symptoms into organ system categories, the review of systems is limited in terms of its personalization and in its ability to discover actionable root causes of illness and disease,” says IFM Director of Medical Education Robert Luby, MD. “We advocate the functional medicine approach, which goes beyond the cataloguing of symptoms to include an investigation of the personalized antecedents, triggers, and mediators of physiological dysfunction that each patient has experienced in their lifetime. This is an evidence-based approach that provides a level of precision and personalization not achieved by the standard review of systems. Most importantly, it is more effective in identifying actionable root causes of disease. These often include lifestyle factors such as diet, stress, sleep, and physical activity, as well as the health of the gut microbiome and the role of the environmental exposome, including infections, allergens, toxins, and social determinants of health.”

The functional medicine model is an individualized, patient-centered, science-based approach that empowers patients and practitioners to work together to address the underlying causes of disease and promote optimal wellness. It requires a detailed understanding of each patient’s genetic, biochemical, and lifestyle factors and leverages that data to direct personalized treatment plans that lead to improved patient outcomes. By insisting on addressing root causes in addition to symptoms, practitioners become oriented to a multimodal therapeutic approach to complex chronic disease that yields better outcomes for patients. The functional medicine approach to the process of taking a medical history can help bring about this type of transformation for the medical profession. It has the potential to supersede the review of systems and provide significant value both to individual patients and the healthcare system as a whole.