Early Changes in Billing and Notes After Evaluation and Management Guideline Change

Physician EHR Time and Visit Volume Following Adoption of Team-Based Documentation Support

Importance

Physicians spend the plurality of active electronic health record (EHR) time on documentation. Excessive documentation limits time spent with patients and is associated with burnout. Organizations need effective strategies to reduce physician documentation burden; however, evidence on team-based documentation (eg, medical scribes) has been limited to small, single-institution studies lacking rigorous estimates of how documentation support changes EHR time and visit volume.

Objectives

To analyze how EHR documentation time and visit volume change following the adoption of team-based documentation approaches.

Design, Setting, and Participants

This national longitudinal cohort study analyzed physician-week EHR metadata from September 2020 through April 2021. A 2-way fixed-effects difference-in-differences regression approach was used to analyze changes in the main outcomes after team-based documentation support adoption. Event study regression models were used to examine variation in changes over time and stratified models to analyze the moderating role of support intensity. The sample included US ambulatory physicians using the EHR. Data were analyzed between October 2022 and September 2023.

Exposure

Team-based documentation support, defined as new onset and consistent use of coauthored documentation with another clinical team member.

Main Outcomes and Measures

The main outcomes included weekly visit volume, EHR documentation time, total EHR time, and EHR time outside clinic hours.

Results

Of 18 265 physicians, 1024 physicians adopted team-based documentation support, with 17 241 comparison physicians who did not adopt such support. The sample included 57.2% primary care physicians, 31.6% medical specialists, and 11.2% surgical specialists; 40.0% practiced in academic settings and 18.4% in outpatient safety-net settings. For adopter physicians, visit volume increased by 6.0% (2.5 visits/wk [95% CI, 1.9-3.0]; P < .001), and documentation time decreased by 9.1% (23.3 min/wk [95% CI, -30.3 to -16.2]; P < .001). Following a 20-week postadoption learning period, visits per week increased by 10.8% and documentation time decreased by 16.2%. Only high-intensity adopters (>40% of note text authored by others) realized reductions in documentation time, both for the full postadoption period (-53.9 min/wk [95% CI, -65.3 to -42.4]; 21.0% decrease; P < .001) and following the learning period (-72.2 min/wk; 28.1% decrease). Low adopters saw no meaningful change in EHR time but realized a similar increase in visit volume.

Conclusions and Relevance

In this national longitudinal cohort study, physicians who adopted team-based documentation experienced increased visit volume and reduced documentation and EHR time, especially after a learning period.

Pediatric Primary Care Billing Trends After the 2021 Evaluation and Management Coding Changes

This cross-sectional study examines the differences in billing trends for pediatric patient care compared with adult care after the 2021 evaluation and management (E/M) policy changes.

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

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.

Electronic Health Record Usability, Satisfaction, and Burnout for Family Physicians

Importance

Electronic health record (EHR) work has been associated with decreased physician well-being. Understanding the association between EHR usability and physician satisfaction and burnout, and whether team and technology strategies moderate this association, is critical to informing efforts to address EHR-associated physician burnout.

Objectives

To measure family physician satisfaction with their EHR and EHR usability across functions and evaluate the association of EHR usability with satisfaction and burnout, as well as the moderating association of 4 team and technology EHR efficiency strategies.

Design, Setting, and Participants

This study uses data from a cross-sectional survey conducted from December 12, 2021, to October 17, 2022, of all family physicians seeking American Board of Family Medicine recertification in 2022.

Exposure

Physicians perceived EHR usability across 6 domains, as well as adoption of 4 EHR efficiency strategies: scribes, support from other staff, templated text, and voice recognition or transcription.

Main Outcomes and Measures

Physician EHR satisfaction and frequency of experiencing burnout measured with a single survey item ("I feel burned out from my work"), with answers ranging from "never" to "every day."

Results

Of the 2067 physicians (1246 [60.3%] younger than 50 years; 1051 men [50.9%]; and 1729 [86.0%] practicing in an urban area) who responded to the survey, 562 (27.2%) were very satisfied and 775 (37.5%) were somewhat satisfied, while 346 (16.7%) were somewhat dissatisfied and 198 (9.6%) were very dissatisfied with their EHR. Readability of information had the highest usability, with 543 physicians (26.3%) rating it as excellent, while usefulness of alerts had the lowest usability, with 262 physicians (12.7%) rating it as excellent. In multivariable models, good or excellent usability for entering data (β = 0.09 [95% CI, 0.05-0.14]; P < .001), alignment with workflow processes (β = 0.11 [95% CI, 0.06-0.16]; P < .001), ease of finding information (β = 0.14 [95% CI, 0.09-0.19]; P < .001), and usefulness of alerts (β = 0.11 [95% CI, 0.06-0.16]; P < .001) were associated with physicians being very satisfied with their EHR. In addition, being very satisfied with the EHR was associated with reduced frequency of burnout (β = -0.64 [95% CI, -1.06 to -0.22]; P < .001). In moderation analysis, only physicians with highly usable EHRs saw improvements in satisfaction from adopting efficiency strategies.

Conclusions and Relevance

In this survey study of physician EHR usability and satisfaction, approximately one-fourth of family physicians reported being very satisfied with their EHR, while another one-fourth reported being somewhat or very dissatisfied, a concerning finding amplified by the inverse association between EHR satisfaction and burnout. Electronic health record-based alerts had the lowest reported usability, suggesting EHR vendors should focus their efforts on improving alerts. Electronic health record efficiency strategies were broadly adopted, but only physicians with highly usable EHRs realized gains in EHR satisfaction from using these strategies, suggesting that EHR burden-reduction interventions are likely to have heterogenous associations across physicians with different EHRs.

Consistency is key: documentation distribution and efficiency in primary care

OBJECTIVES

We analyzed the degree to which daily documentation patterns in primary care varied and whether specific patterns, consistency over time, and deviations from clinicians' usual patterns were associated with note-writing efficiency.

MATERIALS AND METHODS

We used electronic health record (EHR) active use data from the Oracle Cerner Advance platform capturing hourly active documentation time for 498 physicians and advance practice clinicians (eg, nurse practitioners) for 65 152 clinic days. We used k-means clustering to identify distinct daily patterns of active documentation time and analyzed the relationship between these patterns and active documentation time per note. We determined each primary care clinician's (PCC) modal documentation pattern and analyzed how consistency and deviations were related to documentation efficiency.

RESULTS

We identified 8 distinct daily documentation patterns; the 3 most common patterns accounted for 80.6% of PCC-days and differed primarily in average volume of documentation time (78.1 minutes per day; 35.4 minutes per day; 144.6 minutes per day); associations with note efficiency were mixed. PCCs with >80% of days attributable to a single pattern demonstrated significantly more efficient documentation than PCCs with lower consistency; for high-consistency PCCs, days that deviated from their usual patterns were associated with less efficient documentation.

DISCUSSION

We found substantial variation in efficiency across daily documentation patterns, suggesting that PCC-level factors like EHR facility and consistency may be more important than when documentation occurs. There were substantial efficiency returns to consistency, and deviations from consistent patterns were costly.

CONCLUSION

Organizational leaders aiming to reduce documentation burden should pay specific attention to the ability for PCCs to execute consistent documentation patterns day-to-day.

Quantifying EHR and Policy Factors Associated with the Gender Productivity Gap in Ambulatory, General Internal Medicine

BACKGROUND

The gender gap in physician compensation has persisted for decades. Little is known about how differences in use of the electronic health record (EHR) may contribute.

OBJECTIVE

To characterize how time on clinical activities, time on the EHR, and clinical productivity vary by physician gender and to identify factors associated with physician productivity.

DESIGN, SETTING, AND PARTICIPANTS

This longitudinal study included general internal medicine physicians employed by a large ambulatory practice network in the Northeastern United States from August 2018 to June 2021.

MAIN MEASURES

Monthly data on physician work relative value units (wRVUs), physician and practice characteristics, metrics of EHR use and note content, and temporal trend variables.

KEY RESULTS

The analysis included 3227 physician-months of data for 108 physicians (44% women). Compared with men physicians, women physicians generated 23.8% fewer wRVUs per month, completed 22.1% fewer visits per month, spent 4.0 more minutes/visit and 8.72 more minutes on the EHR per hour worked (all p < 0.001), and typed or dictated 36.4% more note characters per note (p = 0.006). With multivariable adjustment for physician age, practice characteristics, EHR use, and temporal trends, physician gender was no longer associated with productivity (men 4.20 vs. women 3.88 wRVUs/hour, p = 0.31). Typing/dictating fewer characters per note, relying on greater teamwork to manage orders, and spending less time on documentation were associated with higher wRVUs/hour. The 2021 E/M code change was associated with higher wRVUs/hour for all physicians: 10% higher for men physicians and 18% higher for women physicians (p < 0.001 and p = 0.009, respectively).

CONCLUSIONS

Increased team support, briefer documentation, and the 2021 E/M code change were associated with higher physician productivity. The E/M code change may have preferentially benefited women physicians by incentivizing time-intensive activities such as medical decision-making, preventive care discussion, and patient counseling that women physicians have historically spent more time performing.

Guidance for reporting analyses of metadata on electronic health record use

INTRODUCTION

Research on how people interact with electronic health records (EHRs) increasingly involves the analysis of metadata on EHR use. These metadata can be recorded unobtrusively and capture EHR use at a scale unattainable through direct observation or self-reports. However, there is substantial variation in how metadata on EHR use are recorded, analyzed and described, limiting understanding, replication, and synthesis across studies.

RECOMMENDATIONS

In this perspective, we provide guidance to those working with EHR use metadata by describing 4 common types, how they are recorded, and how they can be aggregated into higher-level measures of EHR use. We also describe guidelines for reporting analyses of EHR use metadata-or measures of EHR use derived from them-to foster clarity, standardization, and reproducibility in this emerging and critical area of research.

The role of organizations in shaping physician use of electronic health records

OBJECTIVE

The aim of the study was to (1) characterize organizational differences in primary care physicians' electronic health record (EHR) behavior; (2) assess within-organization consistency in EHR behaviors; and (3) identify whether organizational consistency is associated with physician-level efficiency.

DATA SOURCES

EHR metadata capturing averaged weekly measures of EHR time and documentation composition from 75,124 US primary care physicians across 299 organizations between September 2020 and May 2021 were taken. EHR time measures include active time in orders, chart review, notes, messaging, time spent outside of scheduled hours, and total EHR time. Documentation composition measures include note length and percentage use of templated text or copy/paste. Efficiency is measured as the percent of visits with same-day note completion.

STUDY DESIGN

All analyses are cross-sectional. Across-organization differences in EHR use and documentation composition are presented via 90th-to-10th percentile ratios of means and SDs. Multilevel modeling with post-estimation variance partitioning assesses the extent of an organizational signature-the proportion of variation in our measures attributable to organizations (versus specialty and individual behaviors). We measured organizational internal consistency for each measure via organization-level SD, which we grouped into quartiles for regression. Association between internally consistent (i.e., low SD) organizational EHR use and physician-level efficiency was assessed with multi-variable OLS models.

DATA COLLECTION

Extraction from Epic's Signal platform used for measuring provider EHR efficiency.

PRINCIPAL FINDINGS

EHR time per visit for physicians at a 90th percentile organization is 1.94 times the average EHR time at a 10th percentile organization. There is little evidence, on average, of an organizational signature. However, physicians in organizations with high internal consistency in EHR use demonstrate increased efficiency. Physicians in organizations with the highest internal consistency (top quartile) have a 3.77 percentage point higher same-day visit closure rates compared with peers in bottom quartile organizations (95% confidence interval: 0.0142-0.0612).

CONCLUSIONS

Results suggest unrealized opportunities for organizations and policymakers to support consistency in how physicians engage in EHR-supported work.

How to make the electronic health record your friend

PURPOSE OF REVIEW

The electronic health record (EHR) has become ubiquitous among healthcare providers. It has revolutionized how we care for patients allowing for instant access to records, improved order entry, and improved patient outcomes. However, it has also been implicated as a source of stress, burnout, and workplace dissatisfaction among its users. The article provides an overview of factors associated with burnout focusing on the pediatrician and pediatric subspecialist workflows and will summarize practical tips based on clinical informatics principles for addressing these factors.

RECENT FINDINGS

Several metrics related to EHR including training, efficiency and lack of usability have been cited as factors associated with burnout. Organizational, personal, and interpersonal factors as well as work culture are more associated with burnout than EHR use.

SUMMARY

Organizational strategies to address burnout include first monitoring metrics including physician satisfaction and wellbeing, incorporating mindfulness and teamwork, and decreasing stress from the EHR by providing training, standardized workflows, and efficiency tools. All clinicians should feel empowered to customize workflows and seek organizational help for improving EHR use.

Ctrl-C: a cross-sectional study of the electronic health record usage patterns of US oncology clinicians

Despite some positive impact, the use of electronic health records (EHRs) has been associated with negative effects, such as emotional exhaustion. We sought to compare EHR use patterns for oncology vs nononcology medical specialists. In this cross-sectional study, we employed EHR usage data for 349 ambulatory health-care systems nationwide collected from the vendor Epic from January to August 2019. We compared note composition, message volume, and time in the EHR system for oncology vs nononcology clinicians. Compared with nononcology medical specialists, oncologists had a statistically significantly greater percentage of notes derived from Copy and Paste functions but less SmartPhrase use. They received more total EHR messages per day than other medical specialists, with a higher proportion of results and system-generated messages. Our results point to priorities for enhancing EHR systems to meet the needs of oncology clinicians, particularly as related to facilitating the complex documentation, results, and therapy involved in oncology care.

Physician Electronic Health Record Use After Changes in US Centers for Medicare & Medicaid Services Documentation Requirements

This cohort study examines changes in physician electronic health record (EHR) documentation time before and after changes in Centers for Medicare &amp;amp; Medicaid evaluation and management requirements.

Re-envisioning the Paradigm for Oncology Electronic Health Record Documentation by Paying for What Matters for Patients, Quality, and Research

This Viewpoint discusses re-envisioning and incentivizing a unique approach to oncology electronic health record documentation.

Association of Evaluation and Management Payment Policy Changes With Medicare Payment to Physicians by Specialty

Importance

US primary care physicians (PCPs) have lower mean incomes than specialists, likely contributing to workforce shortages. In 2021, the Centers for Medicare & Medicaid Services increased payment for evaluation and management (E/M) services and relaxed documentation requirements. These changes may have reduced the gap between primary care and specialist payment.

Objectives

To simulate the effect of the E/M payment policy change on total Medicare physician payments while holding volume constant and to compare these simulated changes with observed changes in total Medicare payments and E/M coding intensity, before (July-December 2020) and after (July-December 2021) the E/M payment policy change.

Design, Setting, and Participants

Retrospective observational study of US office-based physicians who were in specialties with 5000 or more physicians billing Medicare and who had 50 or more fee-for-service Medicare visits before and after the E/M payment policy change.

Exposures

E/M payment policy changes.

Main Outcomes and Measures

Outcomes included physician-level simulated volume-constant payment change, total observed Medicare payment change, and share of high-intensity (ie, level 4 or 5) E/M visits before and after the E/M payment policy change. For each specialty, the median change in each outcome was reported. The payment gap between primary care and specialty physicians was calculated as the difference between total Medicare payments to the median primary care and median specialty physician.

Results

The study population included 180 624 physicians. Repricing 2020 services yielded a simulated volume-constant payment change ranging from a 3.3% (-$4557.0) decrease for the median radiologist to an 11.0% ($3683.1) increase for the median family practice physician. After the E/M payment change, the median high-intensity share of E/M visits increased for physicians of nearly all specialties, ranging from a -4.4 percentage point increase (dermatology) to a 17.8 percentage point increase (psychiatry). The median change in total Medicare payments by specialty ranged from -4.2% (-$1782.9) for general surgery to 12.1% ($3746.9) for family practice. From July-December 2020 to July-December 2021, the payment gap between the median primary care physician and the median specialist shrank by $825.1, from $40 259.8 to $39 434.7 (primary care, $41 193.3 in July-December 2020 and $45 962.4 in July-December 2021; specialist, $81 453.1 in July-December 2020 and $85 397.1 in July-December 2021)-a relative decrease of 2.0%.

Conclusions and Relevance

Among US office-based physicians receiving Medicare payments in 2020 and 2021, E/M payment policy changes were associated with changes in Medicare payment by specialty, although the payment gap between primary care physicians and specialists decreased only modestly. The findings may have been influenced by the COVID-19 pandemic, and further research in subsequent years is needed.

I had not time to make it shorter: an exploratory analysis of how physicians reduce note length and time in notes

OBJECTIVE

We analyze observed reductions in physician note length and documentation time, 2 contributors to electronic health record (EHR) burden and burnout.

MATERIALS AND METHODS

We used EHR metadata from January to May, 2021 for 130 079 ambulatory physician Epic users. We identified cohorts of physicians who decreased note length and/or documentation time and analyzed changes in their note composition.

RESULTS

37 857 physicians decreased either note length (n = 15 647), time in notes (n = 15 417), or both (n = 6793). Note length decreases were primarily attributable to reductions in copy/paste text (average relative change of -18.9%) and templated text (-17.2%). Note time decreases were primarily attributable to reductions in manual text (-27.3%) and increases in note content from other care team members (+21.1%).

DISCUSSION

Organizations must consider priorities and tradeoffs in the distinct approaches needed to address different contributors to EHR burden.

CONCLUSION

Future research should explore scalable burden-reduction initiatives responsive to both note bloat and documentation time.

Using event logs to observe interactions with electronic health records: an updated scoping review shows increasing use of vendor-derived measures

OBJECTIVE

The aim of this article is to compare the aims, measures, methods, limitations, and scope of studies that employ vendor-derived and investigator-derived measures of electronic health record (EHR) use, and to assess measure consistency across studies.

MATERIALS AND METHODS

We searched PubMed for articles published between July 2019 and December 2021 that employed measures of EHR use derived from EHR event logs. We coded the aims, measures, methods, limitations, and scope of each article and compared articles employing vendor-derived and investigator-derived measures.

RESULTS

One hundred and two articles met inclusion criteria; 40 employed vendor-derived measures, 61 employed investigator-derived measures, and 1 employed both. Studies employing vendor-derived measures were more likely than those employing investigator-derived measures to observe EHR use only in ambulatory settings (83% vs 48%, P = .002) and only by physicians or advanced practice providers (100% vs 54% of studies, P < .001). Studies employing vendor-derived measures were also more likely to measure durations of EHR use (P < .001 for 6 different activities), but definitions of measures such as time outside scheduled hours varied widely. Eight articles reported measure validation. The reported limitations of vendor-derived measures included measure transparency and availability for certain clinical settings and roles.

DISCUSSION

Vendor-derived measures are increasingly used to study EHR use, but only by certain clinical roles. Although poorly validated and variously defined, both vendor- and investigator-derived measures of EHR time are widely reported.

CONCLUSION

The number of studies using event logs to observe EHR use continues to grow, but with inconsistent measure definitions and significant differences between studies that employ vendor-derived and investigator-derived measures.

It's time to change our documentation philosophy: writing better neurology notes without the burnout

Succinct clinical documentation is vital to effective twenty-first-century healthcare. Recent changes in outpatient and inpatient evaluation and management (E/M) guidelines have allowed neurology practices to make changes that reduce the documentation burden and enhance clinical note usability. Despite favorable changes in E/M guidelines, some neurology practices have not moved quickly to change their documentation philosophy. We argue in favor of changes in the design, structure, and implementation of clinical notes that make them shorter yet still information-rich. A move from physician-centric to team documentation can reduce work for physicians. Changing the documentation philosophy from "bigger is better" to "short but sweet" can reduce the documentation burden, streamline the writing and reading of clinical notes, and enhance their utility for medical decision-making, patient education, medical education, and clinical research. We believe that these changes can favorably affect physician well-being without adversely affecting reimbursement.

Assessing the use of a clinical decision support tool for pain management in primary care

Objective

Given time constraints, poorly organized information, and complex patients, primary care providers (PCPs) can benefit from clinical decision support (CDS) tools that aggregate and synthesize problem-specific patient information. First, this article describes the design and functionality of a CDS tool for chronic noncancer pain in primary care. Second, we report on the retrospective analysis of real-world usage of the tool in the context of a pragmatic trial.

Materials and methods

The tool known as OneSheet was developed using user-centered principles and built in the Epic electronic health record (EHR) of 2 health systems. For each relevant patient, OneSheet presents pertinent information in a single EHR view to assist PCPs in completing guideline-recommended opioid risk mitigation tasks, review previous and current patient treatments, view patient-reported pain, physical function, and pain-related goals.

Results

Overall, 69 PCPs accessed OneSheet 2411 times (since November 2020). PCP use of OneSheet varied significantly by provider and was highly skewed (site 1: median accesses per provider: 17 [interquartile range (IQR) 9-32]; site 2: median: 8 [IQR 5-16]). Seven "power users" accounted for 70% of the overall access instances across both sites. OneSheet has been accessed an average of 20 times weekly between the 2 sites.

Discussion

Modest OneSheet use was observed relative to the number of eligible patients seen with chronic pain.

Conclusions

Organizations implementing CDS tools are likely to see considerable provider-level variation in usage, suggesting that CDS tools may vary in their utility across PCPs, even for the same condition, because of differences in provider and care team workflows.

Association of Time-Based Billing With Evaluation and Management Revenue for Outpatient Visits

IMPORTANCE

Time-based billing options for physicians have expanded, enabling many physicians to bill according to time spent instead of medical decision-making (MDM) level for fee-for-service outpatient visits. However, no study to date has estimated the revenue changes associated with time-based billing.

OBJECTIVE

To compare evaluation and management (E/M) reimbursement for physicians using time-based billing vs MDM-based billing for outpatient visits of varying lengths.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation used 2019 billing data for outpatient E/M codes and 2021 reimbursement rates from the Centers for Medicare & Medicaid Services. Modeling of generic clinic templates was performed to estimate expected yearly E/M revenues for a single full-time physician working in an outpatient clinic using fee-for-service billing.

MAIN OUTCOMES AND MEASURES

Yearly E/M revenues for different patient visit templates were modeled. The standardized length of return patient visits was 10 to 45 minutes, and new patient visits were twice as long in duration.

RESULTS

Under MDM-based billing, increased visit length was associated with decreased E/M revenue ($564 188 for 30-minute new patient visit/15-minute return patient visit vs $423 137 for 40-minute new patient visit/20-minute return patient visit). Under time-based billing, yearly E/M revenue remained similar across increasing visit lengths ($400 432 for 30-minute new patient visit/15-minute return patient visit vs $458 718 for 40-minute new patient visit/20-minute return patient visit). Compared with time-based billing, MDM-based billing was associated with higher E/M revenue for 10- to 15-minute return patient visits ($400 432 vs $564 188). Time-based billing was associated with higher E/M revenue for return patient visits lasting 20 minutes or longer. The highest modeled E/M revenue of $846 273 occurred for 10-minute return patient visits under MDM-based billing.

CONCLUSIONS AND RELEVANCE

Results of this study showed that the relative economic benefits of MDM-based billing and time-based billing differed and were associated with the length of patient visits. Physicians with longer patient visits were more likely to experience revenue increases from using time-based billing than physicians with shorter patient visits.

Assessing the impact of patient access to clinical notes on clinician EHR documentation

Recent policy changes have required health care delivery organizations provide patients electronic access to their clinical notes free of charge. There is concern that this could have an unintended consequence of increased electronic health record (EHR) work as clinicians may feel the need to adapt their documentation practices in light of their notes being accessible to patients, potentially exacerbating EHR-induced clinician burnout. Using a national, longitudinal data set consisting of all ambulatory care physicians and advance practice providers using an Epic Systems EHR, we used an interrupted time-series analysis to evaluate the immediate impact of the policy change on clinician note length and time spent documenting in the EHR. We found no evidence of a change in note length or time spent writing notes following the implementation of the policy, suggesting patient access to clinical notes did not increase documentation workload for clinicians.

Translating ethnographic data into knowledge, skills, and attitude statements for medical scribes: a modified Delphi approach

OBJECTIVE

While the use of medical scribes is rapidly increasing, there are not widely accepted standards for their training and duties. Because they use electronic health record systems to support providers, inadequately trained scribes can increase patient safety related risks. This paper describes the development of desired core knowledge, skills, and attitudes (KSAs) for scribes that provide the curricular framework for standardized scribe training.

MATERIALS AND METHODS

A research team used a sequential mixed qualitative methods approach. First, a rapid ethnographic study of scribe activities was performed at 5 varied health care organizations in the United States to gather qualitative data about knowledge, skills, and attitudes. The team's analysis generated preliminary KSA related themes, which were further refined during a consensus conference of subject-matter experts. This was followed by a modified Delphi study to finalize the KSA lists.

RESULTS

The team identified 90 descriptions of scribe-related KSAs and subsequently refined, categorized, and prioritized them for training development purposes. Three lists were ultimately defined as: (1) Hands-On Learning KSA list with 47 items amenable to simulation training, (2) Didactic KSA list consisting of 32 items appropriate for didactic lecture teaching, and (3) Prerequisite KSA list consisting of 11 items centered around items scribes should learn prior to being hired or soon after being hired.

CONCLUSION

We utilized a sequential mixed qualitative methodology to successfully develop lists of core medical scribe KSAs, which can be incorporated into scribe training programs.