A dual-group study of notes written by 166,318 outpatient providers in the United States between May 2020 and April 2023 published by Epic Research on Thursday looked at encryption requirements and How the documentation tool has influenced the length of the clinical document.
WHY IT IMPORTANT
Epic Research says in a new report the 2021 changes to the Centers for Medicare and Medicaid Service Management and Assessment CPT billing code are intended to reduce the administrative documentation burden for providers. .
To understand whether the changes had an effect, the researchers evaluated 1.7 billion clinical notes in electronic health records written by 166,318 outpatient providers across specialties and primary care.
They found vendors had an average of 4,628 characters per clinical note in 2020 and increased to an average of 5,002 characters by 2023 (8%).
However, vendors in general have reduced the average time spent per note by 5.4 minutes to 4.8 minutes per note during the same time period.
Although the overall average note length increased during the study period, about 40% of the vendors decreased their average note length. All 10% of those providers include primary care, internal medicine, surgical specialties, dermatology, cardiology, psychiatry, and other specialties.
“This suggests that reducing note length is achievable in almost any discipline,” the researchers said.
“Moreover, nearly 90% of vendors have reduced the average time they spend writing each note.”
Looking at composition methods, Epic researchers also determined that healthcare organizations have reduced their use of SmartTools, a documentation tool that makes it easy to add additional content to notes from other places. – while minimizing copying and pasting in patient charts also reduces their average note length.
TREND TO BIGGER
Last year, researchers from the Perelman School of Medicine at the University of Pennsylvania in Philadelphia published a JAMA research on their work using artificial intelligence to analyze all UPenn Health System notes over a five-year period ending in 2020.
Natural language processing showed superiority over all notes for 1.96 million unique patients. Half of the words are copied from previous notes, and the longer the recording, the higher the level of duplication.
This previous study concluded that the organization of modern EHRs is based on time and authorship driving the popularity of note transcription.
“Duplicate text casts doubt on the authenticity of all information in medical records, making it difficult to find and verify information in everyday clinical work,” the researchers said. .
Recently, Epic and Nuance announced new clinical documentation features that combine ambient and conversational AI with GPT4 to transform provider and patient dialogue interactions into providers of clinical documentation. editable and approved.
Dr Hal said: “This partnership will allow our doctors to focus more completely on the care and treatment of their patients while the AI works behind the scenes to document the encounter. , allowing people and technology to do what they do best without delay.” Baker, CDIO at WellSpan Health, in an Epic statement about the new app.
ON PROFILE
“Organizations that increased note length have seen steady use of SmartTools and increased use of copy/paste functions,” the researchers said in the report.
“These findings are consistent with previous research showing that increased use of SmartTools and copy/paste functions are correlated with longer notes.”
Andrea Fox is the senior editor of Healthcare IT News.
Email: [email protected]
Healthcare IT News is a publication of HIMSS Media.
