Streamline E/M documentation by targeting note bloat

Andis Robeznieks , Senior News Writer

For years, nurses at a large academic medical center would take patients to their exam room and ask them what they wanted their primary care physician to address that day.

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The nurse would record comments on a handwritten piece of paper and then give it to the physician who would type it into the EHR’s visit note. 

“One day the nurse asked: ‘Would it be helpful if, instead of scribbling this on paper, if I just typed it into the EHR?’” recalled family physician Kevin D. Hopkins, MD. “I said ‘Yeah, that would be really helpful because you're handwriting a note. You're telling it to me. I'm trying to type it into the note in real time. We could save like three steps if you just typed it.’” 

Dr. Hopkins cited this as an example of how unnecessary documentation burdens are perpetuated even as simple solutions are readily available.

“The saying in medicine has always been, ‘If it wasn't documented, it wasn't done,’ and we've also had the attitude of ‘If it wasn't documented by the physician, it doesn't count,’” said Dr. Hopkins, a senior physician adviser for professional satisfaction and practice sustainability at the AMA.

Kevin D. Hopkins, MD
Kevin D. Hopkins, MD

Dr. Hopkins will be among the speakers at the Saving Time: Practice Innovation Boot Camp, March 4–5, at the AMA’s Chicago headquarters. Learn about the boot camp and register now. Dr. Hopkins will be giving a presentation to clarify regulatory requirements and encourage physicians to use the updated coding guidelines for evaluation and management (E/M) visits to optimize documentation practices.

The E/M update was the result of a massive effort by the AMA-convened CPT/RUC Evaluation and Management Workgroup, the Centers for Medicare & Medicaid Services and a coalition of 170 state and specialty medical societies to simplify coding requirements and make them more clinically relevant.

“This was an important change that we've been practically begging for—for years, for decades—to help streamline and simplify documentation for office visits specifically,” said Dr. Hopkins, who is also vice chief of the Cleveland Clinic’s Primary Care Institute.

The revisions replaced a system of documenting bullet points related to taking a medical history and exam and then adding up the points to determine a level of service for billing.

“These changes that went into effect in 2021 scrapped all of that and said: ‘Really, you only need to document what's medically necessary for the encounter today,’” Dr. Hopkins explained.

“It’s a big improvement, but by and large physicians, it seems, don’t know about it,” he added. “We’re so busy doing the work that we don’t always have the time learn how to do the work better or more efficiently.”

Physicians are encouraged to put their documentation practices through a de-implementation process (PDF) that “removes the sludge” from their EHR by getting rid of low-value processes or outdated requirements.

“One thing we're not really good at in health care is identifying things that we can stop doing that are no longer necessary,” Dr. Hopkins said. “When we talk about ‘de-implementation,’ that's exactly what we mean, it’s looking for opportunities to reduce low-value tasks.”

Looking for de-implementation opportunities tops Dr. Hopkins’ list of E/M documentation burden-reduction best practices.

Physician practices also should seek to:

  • Recreate or update documentation templates to include only medically necessary information.
  • Delegate work across the care team, rather than following the physician-does-it-all mentality.
  • Build relationships and work with billing and coding experts in your organization. 

“We don’t expect physicians to be professional billers and coders,” Dr. Hopkins said. “Leave it to the professionals, but ask questions, invite them to your physician meetings to give a talk.”

Documentation that may have been necessary prior to 2021 or helpful in tallying up level-of-service bullet points, now just creates clutter. Revising out-of-date templates goes a long way toward reducing note bloat.

“We have a lot of note templates that will pull in past medical history, past surgical history, past family history, past social history, and even a long problem list that’s stored elsewhere in the EHR and it makes our notes unnecessarily long,” Dr. Hopkins explained. “If somebody’s coming in for a knee sprain, it’s not relevant to include in the note the family history of their father having a stroke at 89.”

Information such as medication lists or allergies are already in the EHR and “take up a lot of real estate on the screen,” but editing templates takes time and sometimes even the assistance of an IT professional, so physicians are left with the task of deleting unnecessary information that is automatically added to the note.

“They probably delete the same parts of their note over and over again,” Dr. Hopkins said. “Or worse yet, they're continuing to document unnecessary information, adding to the stress and strain of our clerical tasks associated with care delivery.”

Physicians should also not be afraid to challenge an assertion that unnecessary documentation must stay in the note because regulations require it.

“When you’re told, ‘You have to do it this way because it’s a regulatory issue,’ the next question should always be: Can you show me that regulation?” Dr. Hopkins said.

“If I were going to give one piece of advice, especially about note bloat, it’s: Stop using your old note templates,” he added. “Start writing some notes with a blank screen and see what you actually need, and then redo your note templates based on that.”

Learn more with the AMA Private Practice Simple Solutions webinar on E&M Documentation Burden Reduction (registration required) and the AMA STEPS Forward® toolkit, “Simplified Outpatient Documentation and Coding.”