What Does Documentation Demands Look Like in the Days to Come?

Accurate clinical documentation is not only crucial for providing quality care but also for getting the right, timely reimbursements. No wonder, physicians are required to spend increasing amounts of time at their computers doing work they weren't actually trained for or meant to do. Did you know that the clinical notes of US physicians are four times as long as those in other countries? This could mean that US physicians are spending quite a lot of time outside of clinic hours on notes, leading to "note bloat". A study suggests that the overwhelming burden of clinical documentation all at the expense of face-to-face interactions with patients may be a result of regulatory overload. Not surprisingly, the growing documentation requirements have inadvertently created burdensome workflows that have paved the way for physician burnout. With this said, what does documentation demands look like in the near future? Read on to know more.

Studies on the overwhelming EHR documentation burden physicians face on a daily basis

It has been widely referenced that physicians spend large chunks of time typing in the EHR. A study of 57 physicians working in ambulatory care in four specialties namely, family medicine, internal medicine, cardiology, and orthopedics found that they spent two hours on EHR and desk work for every one hour of time spent in face-to-face patient care. Yet, another study published in the Annals of Internal Medicine observed that physicians spent of 16 minutes and 14 seconds on EHRs for every patient visit. Has EHR data entry tasks become a physician responsibility? Are physicians destined to deal with this endless data entry tasks? Well, what does the future of documentation look like for today's physicians? Let us in this blog see how the 2023 overhaul to E/M office visit coding and documentation will ease physician's administrative workload and how the surge of telemedicine has added to their documentation demands.

New 2023 CPT code set overhaul holds the promise of hope

The good news is that, the 2023 CPT code sets for medical procedures and services released by the AMA are designed to reduce administrative tasks on physicians. The 2023 CPT code sets contain some changes to the codes and guidelines for most evaluation and management services with an effort to significantly reduce the time physicians waste on administrative tasks that divert their time and focus from clinically important activities. The new revisions make the coding and documentation process much easier and flexible for E/M services. This frees up physicians to focus on providing patient-centered care rather than on time-consuming, labor intensive bureaucratic tasks that they weren't trained for or meant to do. AMA President Jack Resneck Jr., M.D said that he wants to make sure that physicians get the much needed administrative relief from the E/M coding updates. In short, the process of coding and documenting all EM services has been simplified in order to streamline and address the administrative burden that prevents physicians from putting patients first.

Surge in telemedicine - Will documentation take a turn for the worse

The surge in telemedicine during Covid-19 has substantially increased the importance and demand for better clinical documentation. TeamHealth prepared and released a document to provide physicians with guidelines on not just documenting telehealth service, but also how it was conducted i.e., whether it was rendered via a real-time interactive audio and video or by audio alone. This is something that physicians need not care to document in the case of regular in office visits. They were also required to document where the patient and physician were physically located, the start and end time of appointment, specific consent for telemedicine obtained from the patient and anything else required by state laws. With the potential to provide safe, efficient and cost-effective health care even to remote and rural areas, telehealth services are here to stay post pandemic too. This being said, physicians may face a heavy documentation burden, as every detail needs to be captured.

Today, physicians feel that documentation has become more like a professional obligation. Even though they have started to accept the demands of documentation as a part of their daily routine there is a glimmer of positivity on the horizon. Yes, the use of medical scribes holds the promise of hope. Medical scribes are one proposed way to lessen physician documentation burden. So, why add to your workload that limits your ability to focus on patients when you can take the help of virtual medical scribes from Scribe4Me to provide real-time documentation directly into your EHRs. You can also avail our hybrid scribing model that leverages the power of AI with highly trained virtual scribes to get real-time notes and the accuracy you look for. To know more about how our services can help reduce the growing documentation demands visit www.scribe4me.com.