Effect of an Electronic Health Record-Based Intervention on Documentation Practices

Abstract

Background Documentation burden is one of the largest contributors to physician burnout. Evaluation and Management (E&M) coding changes were implemented in 2021 to alleviate documentation burden.

Objectives We used this opportunity to develop documentation best practices, implement new electronic health record (EHR) tools, and study the potential impact on provider experiences with documentation related to these 2021 E&M changes, documentation length, and time spent documenting at an academic medical center.

Methods Five actionable best practices, developed through a consensus-driven, multidisciplinary approach in November 2020, led to the creation of two new ambulatory note templates, one for E&M visits (implemented in January 2021) and another for preventative visits (implemented in May 2021). As part of a quality-improvement initiative at nine faculty primary care clinics, surveys were developed utilizing a 5-point Likert scale to assess provider perceptions and deidentified EHR metadata (Signal, Epic Systems) were analyzed to measure changes in EHR use metrics between a pre-E&M changes timeframe (August 2020–December 2020) and a post-E&M change timeframe (August 2021–December 2021). A subgroup analysis was conducted comparing EHR use metrics among note template utilizers versus nonutilizers. Any provider who used one of the note templates at least once was categorized as a utilizer.

Results Between January 2021 and December 2021, the adoption of the E&M visit template was 31,480 instances among 120 unique ambulatory providers, and adoption of the preventative visit template was 1,464 instances among 22 unique ambulatory providers. Survey response rate among faculty primary care providers was 82% (88/107): 55% (48/88) believed the 2021 E&M changes provided an opportunity to reduce documentation burden, and 28% reported favorable satisfaction with time spent documenting. Among providers who reported using one or both of the new note templates, 81% (35/43) of survey respondents reported favorable satisfaction with new note templates. EHR use metric analyses revealed a small, yet significant reduction in time in notes per appointment (p = 0.004) with no significant change in documentation length of notes (p = 0.45). Note template utilization was associated with a statistically significant reduction in documentation length (p = 0.034).

Conclusion This study shows modest progress in improving EHR use measures of documentation length and time spent documenting following the 2021 E&M changes, but without great improvement in perceived documentation burden. Additional tools are needed to reduce documentation burden and further research is needed to understand the impact of these interventions.

Keywords

E&M coding changes - note bloat - documentation - EHR - note templates - implementation

Background and Significance

Physician burnout attributed to the electronic health record (EHR) and increased documentation burden due to a combination of clinical documentation, regulatory, and billing requirements, is plaguing the U.S. health care system.[1] [2] [3] [4] [5] Documentation burden is defined as the increased effort and time demand imposed by the excessive work required to generate clinical documentation in the EHR.[6] [7] Outside office hours, physicians spend another 1 to 2 hours of personal time doing additional computer and clerical work, giving rise to the term “pajama time.”[8] [9] Clinical notes in the United States are nearly four times longer on average than those in other countries, thought to be related to additional compliance and reimbursement documentation that is necessary for clinical notes in the United States.[10] Note templates are EHR documentation aids that insert predefined text or data from a patient's chart into clinical notes, frequently used to streamline the documentation process.[10] [11] These note templates have the potential to standardize documentation practices and alleviate documentation burden, but the variability in use and the extensive individual customization options can be a challenge.[12]

To directly address the continuing problem of documentation burden, the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS) implemented the 2021 billing Evaluation & Management (E&M) rules.[13] [14] [15] These 2021 E&M changes revised the approach to billing for office visits with E&M CPT codes, focusing on medical decision making and time as the main criteria for code selection ([Supplementary Material S1] [ available in the online version]). These E&M changes provided an opportunity for health care organizations to update documentation practices,[16] not just for visits with E&M CPT codes but also for visits with preventative CPT codes.[17] Documentation could be streamlined by removing components of note templates that were previously required for billing purposes. Studies following the 2021 implementation identified a change in the billing codes used for visits without a clinically significant associated decrease in note length or time spent in the EHR.[18] Questions regarding subjective burden and satisfaction in documentation practices remain unanswered.[14] [19]

Objectives

In response to the 2021 E&M changes, we aimed to redesign documentation practices by developing documentation best practices, implementing supporting EHR tools including standardized note templates, and addressing change management with multimodal training materials as part of an organization-wide effort. We also assessed the potential impact on primary care providers via written surveys and EHR use metrics as part of a quality-improvement initiative.

Methods

Setting

Interventions took place at an academic medical center, with over 250 clinics and over 2 million outpatient visits each year, as part of an organization-wide steering committee led by our Chief Medical Informatics Officer in partnership with compliance and revenue cycle, to redesign documentation practices in response to the 2021 E&M changes. Interventions were targeted to ambulatory providers across primary care and ambulatory specialties, as these areas would be most impacted by the 2021 E&M changes. As part of the steering committee, a multidisciplinary workgroup was convened with diverse stakeholders representing primary care, ambulatory specialties, billing and compliance, information technology, and informatics education to identify opportunities to redesign documentation in response to the 2021 E&M coding changes. The workgroup was composed of 22 members with 14 providers from primary care, gastroenterology, and dermatology—selected based on participation in the steering committee as well as other ambulatory informatics committees. The workgroup met about once weekly between October 2020 and May 2021. Interventions were targeted to ambulatory providers across primary care and ambulatory specialties, as these areas would be most impacted by the 2021 E&M changes.

We also assessed the potential impact on primary care providers at nine faculty clinic sites with over 100 providers via written surveys and EHR use metrics as part of a quality-improvement initiative. Primary care faculty was selected because they are our largest group of ambulatory providers, we anticipated the E&M changes to be very relevant to primary care providers due to the new option for time-based billing, and our primary care faculty practices had previously employed use of standardized note templates.

Developing Documentation Best Practices

Our workgroup used evidence-based consensus decision making and expert guidance to develop best practices to streamline documentation in support of the 2021 E&M changes. We specifically leveraged prior evidence pertaining to clinical note assessment and optimization,[20] [21] [22] including resources related to the OpenNotes initiative.[23] [24] We partnered closely with revenue and compliance team members to ensure that workgroup principles aligned with new billing requirements.[23] [25]

Five actionable best practices for documentation with broad applicability across multiple specialties, including (1) center around the “why,” (2) avoid duplication of information readily available elsewhere in the EHR, (3) avoid long lists of reference information, (4) minimize copy and paste, and (5) promote team contribution to documentation. Five structural design principles were also developed to enable application of best practices within the note templates including (1) leverage the Epic Encounter Summary, (2) include interpretations instead of SmartLinks with lists, (3) use collapsible SmartLinks, (4) use hyperlinks to link to chart review information, and (5) contribute to documentation as a team ([Supplementary Material S2] [available in the online version]). Providers could opt to update personal note templates with best practices and structural design principles or leverage new note templates developed by the workgroup. Best practices and design principles were developed by the workgroup in October to November 2020.

EHR Tool Development

Two new note templates were developed using existing functionality within the EHR Epic Systems (Verona, Wisconsin, United States), one template that could be used for visits billed with E&M CPT codes and a second template that could be used for visits billed with preventative CPT codes ([Supplementary Material S3] [available in the online version]). Both templates were developed so that a single note template could be used for multiple visit types (new or return visit to the clinic and telehealth or in-person) and documentation styles (problem-based or assessment and plan charting). Dynamic documentation tools that appear to users when a specific rule is met were leveraged to enhance the specificity of note templates while minimizing note bloat.[15] [16] For example, specific information in the subjective and objective sections appears depending on whether the patient was checked in for a video visit or clinic visit ([Supplementary Fig. S1] [available in the online version]). We also created an optional time-based billing attestation tool to support time-based billing as a new component of the 2021 E&M changes. This tool would disappear if the provider opted to use a different billing method. We identified an exhaustive list of relevant information that could be made available in the EHR encounter summary instead of within the note template. This included diagnoses, medications, history, orders placed during the visit, vitals and flowsheet data from the visit, patient instructions, patient communications, media from the visit, and patient instructions. The E&M visit note template was implemented in January 2021, and a preventative visit note template was implemented in May 2021.

The level of service calculator was updated to reflect the 2021 E&M guidelines as a tool that can be used to help determine level of service for new and established visits. The medical decision-making tab now shows the updated criteria that constitute each level of service. The time-based billing tab now included buttons for times that a provider could select or an option to enter the time spent on the visit that day. The level of service calculator updates and the EHR encounter summary updates were implemented in January 2021.

Multimodal Training Materials

Multimodal forms of education and communication were implemented as a part of the organization-wide steering committee to increase awareness of the 2021 E&M changes and supporting EHR tools. Multiple knowledge base articles and a 15-minute e-learning module were developed by our informatics education team to cover the key E&M changes, best practices, and EHR tools ([Supplementary Figs. S2] and [S3] in [Supplementary Material S4] [available in the online version]). Email communications were sent out with links to these articles starting November 2020 and views or module completions were tracked. Lastly, relevant information was presented at over 15 department meetings across our organization. All training was voluntary or “opt-in,” up to six email reminders were sent to clinicians who had not completed the e-learning module to encourage completion. Training materials starting November 2020 included information about the E&M changes, the level of service calculator updates, the EHR encounter summary updates, and the E&M visit note type. Additional training material about the preventative visit note type was shared with primary care clinicians starting in May 2021.

Written Surveys

A written survey with four closed-ended questions was developed utilizing a 5-point Likert scale ranging from “Strongly Agree” to “Strongly Disagree” to assess providers' perceptions related to documentation optimization interventions including satisfaction with amount of time spent documenting notes in the EHR, and the degree to which the 2021 E&M changes provided an opportunity to reduce documentation burden ([Supplementary Material S5] [available in the online version]). If providers reported using one or both of the new note templates, they were asked to provide self-reported satisfaction with the new note template. If providers reported not using a note template, they were asked to report barriers to using the new standardized note templates, and they were able to select more than one barrier to the use of note templates. Face and content validity was assessed with 2 experts (1 member from the working group with extensive informatics experience and 1 primary care researcher outside of the working group) as well as peer review with 3 primary care providers (2 members from the working group and 1 primary care provider from primary care faculty leadership) to iterate on survey development. In December 2021, nonanonymized surveys were emailed to all 107 providers in our organization's academic primary care division, utilizing voluntary response sampling.

Survey Analysis

Survey completion was defined as any survey response where one or more questions were answered. Each item on the survey was scored individually and items were scored by calculating the proportion of responses for each specific category (e.g., “Strongly Agree”) by dividing the number of responses in that category by the total number of respondents for that survey item.

EHR Use Metric Analysis

Deidentified EHR metadata (Signal, Epic Systems) of EHR use metrics were analyzed for providers at faculty primary care clinic sites. Epic Signal data provide monthly aggregate data for individual providers for each EHR use metric. We analyzed time in notes per appointment (min) and documentation length (character count). Providers were included in the analysis if they had EHR use metric data available at any point during either the pre-E&M change timeframe or post-E&M change timeframe. Providers were excluded from the analysis if they (1) did not have EHR use metrics in both pre- and post-timeframes, (2) worked in primary care subspecialty clinics, or (3) were house staff. A one-sample t-test was used to measure mean difference in EHR use metrics between a pre-E&M change timeframe (August 2020–December 2020) and a post-E&M change timeframe (August 2021–December 2021). For each EHR use metric, a subgroup analysis was performed to measure changes among utilizers versus nonutilizers of each of the new note templates using Welch's two-sample t-test. Any provider who used one of these templates at least once was categorized as a utilizer. All statistical analyses were performed in R (RStudio 2021.09.2 + 382) with an α level of statistical significance of 0.05..

Note Template Adoption Analysis and Ethical Approval

EHR metadata were analyzed to assess the adoption of the two new note templates between January 2021 and December 2021 across our organization as well as amongst the faculty primary care clinics.

The Institutional Review Board determined that the project was exempt from formal review on the basis of quality improvement.

Results

Organization-Wide Metrics

The E&M visit note type was implemented in January 2021, and the preventative visit note type was implemented in May 2021. Both were made available for use throughout our organization. Between January 2021 and December 2021, the adoption of the two new note templates across our organization reached a total of 31,480 instances for the E&M visit template among 120 unique providers, and 1,464 instances for the preventative visit template among 22 unique providers. Knowledge base articles had over 1,400 views. A 15-minute optional eLearning course assigned to all ambulatory providers at our organization had a total completion of over 4,700.

Primary Care Metrics

Adoption of the two new note templates among faculty primary care clinics between January 2021 and December 2021 was 8,435 instances for the E&M visit template and 548 instances for the preventative visit template ([Supplementary Material S6] [available in the online version]). The survey response rate in the faculty primary care clinics was 82% (88/107). Among 88 survey respondents ([Table 1]), 55% (48/88) believed the 2021 E&M changes provided an opportunity to reduce documentation burden, and only 28% (25/88) reported satisfaction with time spent documenting. Among providers who reported using one or both of the new note templates, 81% (35/43) reported favorable satisfaction with the E&M note template and 89% (16/18) reported favorable satisfaction with the preventative visit note template. There were no missing values for these survey questions. Among providers who reported not using one or both of the new templates, common barriers included providers' preference to using their own note templates (45% (34/75 barriers) for the E&M note, 37% (38/103 barriers) for the preventative note) and providers being unaware that the new note templates existed (20% (15/75 barriers) for the E&M note, 38% (37/103 barriers) for the preventative note) ([Supplementary Material S7] [available in the online version]).

Table 1 Written survey results distributed to all providers within academic primary care division

Likert scale response	Strongly agree	Somewhat agree	Neither agree nor disagree	Somewhat disagree	Strongly disagree
Survey results among respondents who used a note templates
Satisfaction with E&M visit note template (n = 43)	42% (18/43)	40% (17/43)	14% (6/43)	5% (2/43)	0% (0/43)
Satisfaction with preventative visit template (n = 18)	33% (6/18)	56% (10/18)	11% (2/18)	0% (0/18)	0% (0/18)
Survey results among all survey respondents
Believed the 2021 E&M changes provided an opportunity to reduce documentation burden (n = 88)	9% (8/88)	45% (40/88)	30% (26/88)	14% (12/88)	2% (2/88)
Satisfaction with time spent documenting (n = 88)	5% (4/88)	24% (21/88)	17% (15/88)	35% (31/88)	19% (17/88)

Abbreviation: E&M, Evaluation and Management.

Of the 107 providers in our organization's faculty primary care clinic sites in December 2021, 98 providers (physicians and advanced practice providers) had EHR use metric data available at any point during either the pre-E&M change timeframe or post-E&M change timeframe. A total of 17 providers were excluded from the analysis because they did not have EHR use metrics in both pre- and post-timeframes, either because they were on leave during the preintervention timeframe or joined the organization after the preintervention timeframe. Another 17 providers were excluded from the analysis because they worked in primary care subspecialty clinics or were house staff. In addition, 64 providers were included in the final analysis EHR use metric analyses, which revealed a small, yet significant reduction in time in notes per appointment (−0.84 minutes, 7.8%, p = 0.004; [Table 2]). When we compared utilizer and nonutilizer subgroups, we found note template utilization to be significantly associated with a decrease in mean documentation length (p-value = 0.034; [Table 3]).

Table 2 EHR use metrics before and after 2021 E&M changes for faculty primary care providers

EHR use metrics	Mean change	p-Value	95% CI
Documentation length (character count)	−54.24	0.4476	(−196.065, 87.5890)
Time in notes per appointment (minutes)	−0.84	0.004	(−1.4073, −0.2824)

Abbreviations: CI, confidence interval; EHR, electronic health record; E&M, Evaluation and Management.

Table 3 EHR use metrics subgroup analysis for utilizers vs. nonutilizers of new note templates

EHR metric	Mean change utilizer subgroup	Mean change nonutilizer subgroup	p-Value	95% CI
Documentation length (character count)	−274.026	69.057	0.0337	(28.0029, 658.1644)
Time per appointment (min)	−0.59	−0.99	0.4726	(−1.5127, 0.7106)

Abbreviations: CI, confidence interval; EHR, electronic health record.

Discussion

In response to the 2021 E&M changes, we aimed to redesign documentation practices by developing five documentation best practices with broad applicability across multiple specialties, as well as the development of five structural design principles to enable application of the best practices within note templates. These best practices and design principles were rooted in three core foundational design principles, including redesigning note templates to improve readability of notes, eliminating information no longer necessary in the 2021 E&M coding changes, and minimizing redundancy of information in the note that can be discreetly available in the EHR encounter summary.

We were able to promote the adoption of new note templates across our organization, particularly for the E&M note template type. Survey results from faculty primary care clinics indicated favorable satisfaction with the new note templates among survey respondents. We were also able to understand barriers to adoption which can help improve future interventions, such as providers' preference to using their own note templates.

While 55% of our survey respondents believed the 2021 E&M changes provided an opportunity to reduce documentation burden, the vast majority (72%) remain dissatisfied with the time spent documenting in the EHR. Overall, we noticed a slight reduction in documentation length and a statistically significant reduction in time in notes per appointment; however, the magnitude of change was small. These data suggest that the 2021 E&M changes with interventions targeting note templates alone might be helpful, but likely insufficient to reduce documentation burden. We hypothesize this is due to the heterogeneity of documentation tools apart from note templates such as problem-based charting, medical scribes, and ambient scribes solutions, as well as variability in provider preferences to use these tools. This highlights a need for additional interventions and a better understanding of the potential impact of these interventions especially given known limitations with the use of EHR use metric data.[26] [27]

Note template utilization was associated with a statistically significant reduction in note length, but the magnitude of change was small. These data suggest that use of standardized documentation templates may help reduce “note bloat,” but further research is needed to understand the impact of standardized documentation templates, including an analysis comparing the quality of clinical documentation generated with and without the use of note templates to evaluate the effectiveness of note templates and any subsequent changes to billing practices.

Our note templates, surveys, and EHR use metric analyses focused on primary care settings; however, medical sub-specialties also experience documentation burden,[28] and this is a limitation of this study as the impact of 2021 E&M changes and documentation optimization interventions likely vary in subspecialty settings. Additional limitations of the study are that surveys were nonanonymized, and we did not conduct formal survey validation, such as criterion and construct validation.[29] Analysis comparing those who completed the voluntary training module versus those who did not was not completed, and this could have helped us understand the potential impact of training interventions. The measure of note template utilization is also limited as providers could opt to update personal note templates and/or copy and paste from the new note templates to create customized individual templates. Providers who copied the template and made personal edits would not be considered utilizers, but may have still changed their documentation practices. The two note templates were implemented at different times (one in January and another in May) and this likely impacted note template utilization for 2020. There are also known limitations to the use of EHR metadata, especially with approximations of time-based metrics,[30] as well as studies involving natural experiments lacking a randomized controlled methodological design.[31]

Future areas to explore could leverage natural language processing techniques to identify instances where standardized note template content is utilized through copy and paste. Edit distance analysis could be valuable to assess the specific changes that are made to standardized note template content during clinical documentation. Qualitative interviews of providers could also help to better understand provider documentation preferences and perceptions of standardized note templates. These methodologies could provide better insight into the specific modifications providers are making to note templates and to help uncover barriers to effective use and facilitate targeted improvements to support documentation practices.

Conclusion

In response to the 2021 E&M changes, we aimed to redesign documentation practices by developing documentation best practices, implementing supporting EHR tools including standardized note templates, and addressing change management with multimodal training materials. We measured the potential impact to understand if we were making a useful change at the health system level. This study shows modest progress in improving EHR use measures following the 2021 E&M changes, but without great improvement in provider's documentation burden. We hypothesize that the 2021 E&M changes alone are insufficient to reduce burden, but further research, enhanced policy by the AMA and CMS, and innovative interventions are needed to reduce documentation burden during this physician burnout crisis.

Clinical Relevance Statement

Documentation burden, including documentation of clinical notes in the EHR, has been an ongoing contributor of physician burnout. The 2021 E&M changes were implemented to directly address the documentation burden issue, and provided an opportunity to update documentation practices. We aimed to redesign documentation practices at our organization by developing documentation best practices, implementing supporting EHR tools including standardized note templates, and addressing change management with multimodal training materials.

Multiple Choice Questions

1. Dynamic documentation tools embedded into note templates were helpful to streamline documentation in all of the following ways except:

   • A single note template can be used for in-person and clinic visits

   • A single note template can be used for return and new patient visits

   • A single note template can be used for problem-based charting or Subjective, Objective, Assessment and Plan (SOAP) charting

   • A single note template can be used for E&M-based visits as well as preventative care visits

   Correct Answer: The correct answer is option d. Separate note templates were created for E&M-based visits and preventative care visits due to the different billing requirements and necessary documentation for these visit types.

2. Utilization of new standardized note templates was associated with:

   • Reduction in work outside of work

   • Reduction in time in notes per appointment

   • Reduction in note length

   • Increase in note length

   Correct Answer: The correct answer is option c. Subgroup analyses among utilizers (n = 23) versus nonutilizers (n = 41) revealed that note template utilization was associated with reduced note length. While a statistically significant reduction in time in notes per appointment between pre- and post-E&M changes measurements was identified, template utilization was not associated with these metrics.

Conflict of Interest

None declared.

Protection of Human and Animal Subjects

This minimal risk study was determined by the Institutional Review Board (IRB) to be exempt from formal IRB review on the basis of quality improvement.

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Publication History

Received: 05 January 2024

Accepted: 14 July 2024

Accepted Manuscript online:
17 July 2024

Article published online:
25 September 2024