Documentation burden is a significant issue for family physicians due to competing demands. These demands include organizational documentation guidelines that may not reflect national guidelines, ever-changing clinical workflows that add more work for clinicians, and electronic health record (EHR) systems that often require multiple entries and clicks to meet billing requirements. In 2021, the Centers for Medicare and Medicaid Services (CMS) revised its documentation guidelines for evaluation and management (E/M) services, which simplified the billing requirements for these visits. However, many physicians still struggle to balance their time between patient care and documentation.^1,2 Simplifying EHR features and documentation requirements at an organizational level can reduce the burden on individual physicians and spur more efficient note writing, which leaves more time for direct patient care and makes practice more fulfilling.

This article will describe the approach our organization took to simplify its EHR and improve note-writing efficiency and will offer tips for individual clinicians to improve their own documentation.

THE IMPROVEMENT PROCESS

Burdensome documentation may feel like a problem that is too big to solve, but it can be approached like any other practice problem using continuous process improvement.

Start at the top

When working on any change in clinical practice, including reducing documentation burden, having buy-in from leadership is critical. Leaders must be invested in the project's success, able to allocate the necessary resources, eager to highlight the team's work, and willing to allow the team flexibility to develop, pilot, and implement changes. Leadership involvement during project formation helps ensure that appropriate, attainable, and realistic goals are set from the start.

In our case, institutional leadership recognized widespread problems with documentation efficiency, including the fact that our notes had not changed significantly following the release of the 2021 E/M guidelines. Our department chair was committed to easing documentation burden and approved a team of faculty to work with the Information System Development (ISD) team to identify improvements. The chief medical information officer developed the concept of “Notes 2.0,” an institutional approach across departments to streamline note writing, and the practice medical director sponsored the project.