A Pernicious Paradox

Paul Arden suggested that “if you can’t solve a problem, it’s because you’re playing by the rules.” When applied to clinical documentation, it seems most clinicians are perhaps playing by the wrong rules.?

Despite the transformative revisions to the E/M coding guidelines that took effect on January 1st, 2023, millions of clinicians using EHRs still burn time and effort constructing lengthy and difficult to follow clinical notes. Over the past 15 years, while EHRs enable providers to more easily copy-forward, copy-paste, and insert prefabricated templates, these lengthier clinical notes make it harder to discover the relevant information to care for patients.?

The authors of this insightful July 6, 2023 study from Epic Research reviewed 1.7 billion notes and identified a pernicious paradox: clinicians are spending less time creating lengthier notes. So even as sophisticated EHRs and patient portals enable easier patient access to these visit notes, the clinical content often lacks clarity, making it difficult to discern the recommendations and key next steps.?

If clinicians were to incorporate the 2023 guidelines that enable them to primarily focus on documenting thoughtful and clear Assessments & Plans, then we may more effectively and efficiently capture what is discussed and decided during those impactful visits. Otherwise we continue to inadvertently overlook and under-appreciate the broader cost and harm to patient outcomes and provider experience as we continue to play by the wrong rules.