brand logo

More efficient note writing through EHR simplification can reduce physicians' documentation burden and make practice more fulfilling.

Fam Pract Manag. 2022;29(4):19-24

This content conforms to AAFP criteria for CME.

Author disclosures: no relevant financial relationships.

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.

KEY POINTS

  • Documentation burden is a multifactorial problem resulting from complicated billing guidelines, the lack of truly user-friendly documentation tools within EHRs, and clinician culture and behavior.

  • To improve efficiency in the way we write notes requires organizations and clinicians to embrace a culture of continuous process improvement.

  • The authors' project to reduce documentation burden involved leadership buy-in, education on the new E/M guidelines, a multidisciplinary team, standardized EHR tools, and iteration.

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.

Already a member or subscriber?  Log In

Subscribe

From $80
  • Immediate, unlimited access to all FPM content
  • More than 36 CME credits/year
  • AAFP app access
  • Print delivery available
Subscribe

Issue Access

$39.95
  • Immediate, unlimited access to this issue's content
  • CME credits
  • AAFP app access
  • Print delivery available

Article Only

$25.95
  • Immediate, unlimited access to just this article
  • CME credits
  • AAFP app access
  • Print delivery available
Interested in AAFP membership?  Learn More

Continue Reading

More in FPM

More in Pubmed

Copyright © 2022 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions for copyright questions and/or permission requests.