The Future of Documentation Demands in Healthcare

You’ve just wrapped up another patient visit, and now it’s on to the next. Well, at least in a perfect world. The reality, though, is that you’ll need to find the time to deal with the documentation demands of that previous visit—or be forced to take it home with you for the night. 

As we’ve previously discussed, documentation is the most daunting aspect of a clinician’s day. Whether it’s due to an overly complicated Electronic Health Record (EHR) system or all of the newly adopted measures you must now take due to the pandemic, the truth of the matter is that documentation demands are time consuming and tedious. They’re difficult and downright draining. And they’re the leading cause of burnout among clinicians today.

Code Overhaul Points to Positive Progress 

Clinicians do not choose healthcare as their profession to document and type all day. That said, quality and timely documentation is a vital part of providing patient care.

According to one recent article by Healthcare Innovation, recent changes to coding and documentation will start to make physicians’ lives easier. 

“Some industry stakeholders are hopeful that physicians’ documentation-caused frustrations will soon be lessened, thanks to a recent overhaul to the codes and guidelines for office and other outpatient evaluation and management (E/M) services that was part of the 2021 Current Procedural Terminology (CPT) code set published by the American Medical Association (AMA),” the article states.

According to the article, these E/M modifications—the first significant changes in 25 years—include: 

• Eliminating history and physical exam as elements for code selection
• Allowing physicians to choose the best patient care by permitting code level selection based on medical decision-making (MDM) or total time.
• Promoting payer consistency with more detail added to CPT code descriptors and guidelines.

When asked specifically about the future of documentation reform and what it will take for physicians to be generally satisfied, Heidi Twedt, M.D., Associate Chief Medical Information Officer (CMIO) at University of Wisconsin, said that one particular struggle stems from the note being seen as a standalone entity. “It really needs to be seen as just one element of what the patient care that day entailed,” she said. “Other documentation may include orders that I’ve placed or interventions that the nursing staff had with the patient, for example. Historically, the provider has been asked to reproduce a lot of that work in their notes, even though others help to facilitate that work. So, I think that’s a mindset change that we all need to think about as we optimize the EHR and then view the medial record.”

Telemedicine Piles on Even More Documentation Demands

As the expectations of healthcare and documentation continue to evolve, so too are the ways in which clinicians are interacting with their patients. While telemedicine practices have been gaining momentum over the past several years, the onset of the pandemic has only heightened the necessity of these technology-based connections.

To help clinicians navigate telemedicine documentation, Team Health prepared a document to encapsulate its recommended list of best practices. In it, they state the importance of documenting not only the service that was provided, but how it was provided as well—something that clinicians previously would not need to care for when documenting an in-person visit. 

Because of this increased need for out-of-office visits, documentation could also take a turn for the worse in the future when it comes to everything that must be captured. As an example, Team Health’s reference document includes documentation of specific consent for telemedicine, documentation of where the patient is physically located and where the clinician is located and documentation of if the service was provided via technology with synchronous audio/video or by audio alone.

While clinicians have had no choice but to accept the many demands of documentation as part of their everyday duties, there is hope that positive progress is on the horizon. Although these demands will likely never disappear completely, any step in the right direction is a welcome one for clinicians who already feel the weight of the world on their shoulders.

Physicians Angels is the industry’s first virtual scribe company, providing real-time documentation directly into the physician’s EMR, along with Virtual Back Office services. Our services save the physician an average of 10 hours per week, thereby improving patient throughput and contributing to a better work/life balance for the physician and office staff. To learn more, visit physiciansangels.com or contact us.