The Future of Clinical Documentation: One Expert Parses the Landscape
With the implementation of electronic health records (EHRs), the shift to electronic documentation has led to some unfortunate unplanned consequences. For one, clinical notes in U.S. provider organizations are exceedingly long—around four times the length of notes in other countries—which means clinicians are spending quite a bit of time writing notes outside of office hours. What’s more, there’s the phenomenon of “note bloat”—the electronic agglutination of physician notes and other data, clogging the EHR with so much content, often poorly organized, leading to physician frustration and potentially medical errors.
Put altogether, physicians spend large chunks of their days documenting patient encounters using EHRs. Back in 2016, a commonly referenced study, published in the Annals of Internal Medicine, found that for every hour physicians provide direct clinical face time to patients, nearly two additional hours are spent on EHR and desk work within the clinic day. A more recent study from last year revealed that physicians spent an average of 16 minutes and 14 seconds per encounter using EHRs, with chart review (33 percent), documentation (24 percent), and ordering (17 percent) functions accounting for most of the time.
However, some industry stakeholders are hopeful that physicians’ documentation-caused frustrations will soon be lessened, thanks to a recent overhaul to the codes and guidelines for office and other outpatient evaluation and management (E/M) services that was part of the 2021 Current Procedural Terminology (CPT) code set published by the American Medical Association (AMA). The E/M office visit modifications—the first significant ones in 25 years—include:
- Eliminating history and physical exam as elements for code selection.
- Allowing physicians to choose the best patient care by permitting code level selection based on medical decision-making (MDM) or total time.
- Promoting payer consistency with more detail added to CPT code descriptors and guidelines.
Set to be adopted by the Centers for Medicare and Medicaid Services (CMS) starting Jan. 1, 2021, AMA leaders say “These foundational modifications were designed to make E/M office visit coding and documentation simpler and more flexible, freeing physicians and care teams from clinically irrelevant administrative burdens that led to time-wasting note bloat and box checking.” Barbara Levy, M.D., a former chair of the AMA/Specialty Society RVS Update Committee (RUC) and co-chair of the AMA-convened workgroup that was responsible for the coding overhaul, recently described the changes as “coming back to what is clinically important,” clarifying codes to reduce the need for auditing, reducing “note bloat,” ensuring that payment for E/M services was resource based, and removing “all the things that currently drive us crazy.”
The onus will be on EHR vendors to do their part, too. Officials from Epic Systems, for instance, assert that one of its recent software updates reminds clinicians that they no longer need to include an exhaustive review of a patient’s past history in the note. The update also comes with advanced analytics to find clinicians who could use extra help saving time on notes, and lots of other tools to help providers reduce note bloat, Epic officials say. These updates are already in effect at health systems across the country, including at UW Health, the academic medical center and health system for the University of Wisconsin, where Heidi Twedt, M.D., is the associate chief medical information officer (CMIO).
To further discuss documentation reform, and the impact of the AMA’s changes, Healthcare Innovation Managing Editor Rajiv Leventhal spoke with at Twedt, who was previously at the South Dakota-based Sanford Health for 21 years, where she was CMIO there for nearly six of them. Below are excerpts of that discussion.
Lots of research continues to point to clinicians spending far too much time documenting and note-taking, rather than on patient care. Can you describe what the specific frustrations have been for clinicians in this area?
When you think about the notes that the provider writes, there's actually a lot of audiences for that note. One might be meeting coding regulations for the level of service that they would drop for that visit. One might be fulfilling legal needs. One might be their own communication with their future self, or their partners who care of the patient down the road. And when you have all of those audiences interested in what's in your note, over time, the requirements for what you're being asked to put in your note tend to grow and grow.
In which ways have physician note-writing needs been reformed within the EHR? What’s still necessary for improvement in this area?
In 2020, CMS regulations changed so that parties other than just the billing provider could help take the history. So I think that was a step in the right direction because you could rely upon other members of the care team to help you gather information about the patient. What has changed in 2021 is the fundamental way that the billing for a clinic visit or for an outpatient visit is calculated based on the documentation. It used to be a complicated algorithm [involving] how many elements of history, physical exam and medical decision making did I document? And now, the algorithm has been [trimmed] down to be just [based on] medical decision making or total time.
One of providers’ biggest complaints about notes in the modern era is that it has lost the story of the patient’s course because we were busy fulfilling these elements of history and physical exam, etc. So maybe we sort of lost the big picture because [we were] documenting so many elements, and providers felt the need to pull all of the recent lab results or recent radiology results into their note. That made it hard to find the “guts” of the note—the truly most important medical information.
What are some strategies your clinical informatics teams have put in place to reduce note length?
The most successful thing I have found is helping to make it easy to do the right thing. That [entails] giving providers the best tools to make a good note that fits the current regulations. So, giving them the foundational templates, the right tools for easy note generation—and that might be voice-to-text, or templates, or other EHR tools. We also then have to educate them on what does and doesn't need to be in their notes in different clinical situations for billing [purposes].
Can you discuss the dynamic, from the CMIO’s perspective, of working with clinicians in this area?
It’s always a group project to help deliver this kind of information and this kind of change to a physician group. You’re working with coding and compliance, the legal department, the billing department, and others, to help make sure that everyone is on board with the plan so that the providers get one cohesive message about what best practice is, rather than being told one thing by one team only to be told something else by another team the next week.
Do you believe the OpenNotes movement has served as a driver for documentation reform, in the sense that if patients are viewing physician notes it means that those notes must be presentable, readable, and understandable?
I think OpenNotes has really brought another audience to the table; as I mentioned, there are multiple audiences for the note. The patient could always see his or her own notes, but it generally involves going to the organization’s HIM department or requesting records, so it isn’t always easy to [access] them. Now, as soon as I sign my notes, it's there for the patient. And I think that does make us think more about layout of the note and the ease of finding the information now that there's another reader.
When you think about the future of documentation reform and what it will take for physicians to be generally satisfied, how will you and UW Health measure progress?
One struggle that we have is the note being seen as a standalone entity, when it really needs to be seen as just one element of what the patient care that day entailed. Other documentation may include orders that I've placed or interventions that the nursing staff had with the patient, for example. Historically, the provider has been asked to reproduce a lot of that work in their notes, even though others help to facilitate that work. So I think that's a mindset change that we all need to think about as we optimize the EHR and then view the medical record.
To the degree we can measure it, the time it takes providers to generate their notes, and perhaps the time they spend using the electronic medical record after hours, are two places we can look to see if we've made improvements. We can also look at note length as a potential way to measure if we're making improvements in note bloat. The reality, though, is that sometimes the note needs to be longer because the medical care was more complicated, or the decision making was more complicated. So, a shorter note isn't always better, but a note that is longer than it needs to be shouldn’t be our goal.
The coding changes went into place on Jan. 1. I was just looking at our data here at UW Health since that date; our notes have not magically dropped in length or in the time it takes to generate them. So I think that proves that this is adaptive change that we need to make with our providers. It’s a big change to think about what really needs to be in my note, as opposed to what have I been told over the years needs to be in there. The current coding regulations [prior to 2021] went into place in 1995, so a whole lot of us—myself included—have never practiced medicine before these were in place. So we were sort of trained to meet these codes in our training, and now we need to just sort of reboot and think about, how can this be different?
