Patients Over Paperwork: Clinicians weigh in

At my yearly physical exam, my doctor and I talked about work, skiing next season and of course COVID-19. The chit chat always helps me get ready with my medical checklist to discuss. During our chat, I asked my provider if she is taking advantage of the 2021 guideline change for Evaluation and Management (E/M) documentation. Turns out she knew about the guidelines but felt that it was just easier to keep documenting in the style she was accustomed to. The work of changing all the different templates in the electronic health record (EHR), as well as her current workflow, was too overwhelming, so she left the initiative by the wayside. I felt like this was a missed opportunity given what I do every day!  

We are nearly two years into another initiative from the Centers for Medicare & Medicaid Services (CMS) called Patients Over Paperwork. The federal program was created to reduce red tape and administrative burden on clinicians when providing care to patients. The overall goal is to free up more time for clinicians to spend with patients. 

I never thought in my years working in health care that I would ever ask a clinician to document less rather than more. I’ve spent most of my career discussing documentation guidelines and the requirement for additional documentation. My colleagues and I had a saying, “If it wasn’t documented, it wasn’t done.” I love the paradigm shift, but I think the CMS guidelines were somewhat confusing. Since the inception of this initiative, I have always wondered, “Who is taking advantage? Is the time coming back to the patients? Do the providers feel less administrative burden?” 

I took to the streets (okay email) to ask more clinicians about their thoughts on the initiative that was rolled out two years ago. I loved the candor of the responses that I received. Here is a sample of responses I received.  

• “The new coding guidelines definitely decrease the amount of click boxes (i.e., review of systems) that physicians feel the need to complete, so I guess last year I felt as if I was focused more on simply justifying the complexity of the patient, which SHOULD be my sole focus when documenting. Does this free up time with patients? Yes, although I hadn't really thought about that as a massive time savings.” 

• “The E/M guideline change hasn’t done much to give me more time with patients. It does decrease the tedious cognitive burden of counting bullet points. It has been at least a step in the right direction.” 

• “I love the new guidelines. They make my job teaching residents so much easier. I pull out the American Medical Association (AMA) grid and tell them I will teach them how to code in less than five minutes.” 

I appreciated the different perspectives from the clinicians and thought I would also like to see it from the lens of an administrator. I reached out to a large multi-specialty organization that prepared its clinicians for the changes. The organization was very proactive and felt that preparing for the change was the key to success. The administrator said that clinicians now have more time with their patients as a result and feel less of the burden. I love a good story! 

One clinician used a study as a way of answering my question. The provider gave me a copy of a study published by the Annals of Internal Medicine which I found fascinating – someone actually did a study! The objective of the study was to measure the length of documentation as well as time within an EHR after the guideline change. The study had more than 302,000 clinicians spanning 389 organizations. The study showed shifts in E/M levels, but also reported that there were no meaningful changes in time spent in the EHR or note length. It will take more time and facilitation to bring the intent of Patients Over Paperwork to fruition. The study concluded that scaling best practices tailored to the EHR documentation and its associated burden will facilitate the intent of the initiative.  

I am still in health care today because of the challenging environment. I have never been bored as there are always opportunities to learn and grow. I started working in health care when the first set of E/M guidelines were published. At that time, we were hand typing claims and paper charts were standard operating procedure. I remember one of my after-school jobs was filing paper charts. The manager of the practice told me, “If you misfile, we might never find that chart again.” Oh, the pressure!  

Fast forward 20 plus years and the conversation has turned away from paper and far into the depths of the EHR. The study that clinician provided to me showed shifts in E/M levels of service which is what we as an industry hoped to see. I think the jury is still out as to how this translates to time spent with patients.  

Going back to what my provider said, the front-end work wasn’t done, the provider templates are the same, which didn’t yield a change to her in terms of burden. In my next blog, I will be looking at barriers to the use of the 2021 E/M guidelines and why the guidelines haven’t reached their full potential. Stay tuned! 

Jean Jones is a coding analyst at 3M Health Information Systems.