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

Area of Science:

• Medical Informatics
• Healthcare Quality Improvement
• Physician Documentation

Background:

• Physician burnout is significantly exacerbated by extensive documentation requirements.
• The 2021 Evaluation and Management (E&M) coding revisions aimed to mitigate this documentation burden.

Purpose of the Study:

• To assess the impact of new electronic health record (EHR) tools and documentation best practices on provider experience.
• To analyze changes in documentation length and time spent documenting following the 2021 E&M changes at an academic medical center.

Main Methods:

• Developed and implemented five best practices and two new ambulatory note templates (E&M and preventative visits).
• Conducted provider surveys using a 5-point Likert scale and analyzed deidentified EHR metadata (Signal, Epic Systems).
• Compared EHR metrics between pre- (Aug-Dec 2020) and post-E&M changes (Aug-Dec 2021) timeframes, including subgroup analysis of note template utilizers.

Main Results:

• High adoption rates for new note templates: 31,480 E&M visits and 1,464 preventative visits.
• 82% survey response rate; 55% believed E&M changes could reduce burden, but only 28% were satisfied with time spent documenting.
• Significant reduction in time in notes per appointment (p=0.004); no significant change in overall documentation length (p=0.45).
• Note template utilization correlated with reduced documentation length (p=0.034).

Conclusions:

• The 2021 E&M changes and new EHR tools showed modest improvements in documentation time and length.
• Perceived documentation burden did not significantly improve, indicating a need for further interventions.
• Additional tools and research are necessary to effectively reduce physician documentation burden.