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A twin workforce examine of notes written by 166,318 outpatient suppliers within the U.S. from Could 2020 to April 2023 printed by Epic Analysis on Thursday examined how coding necessities and documentation instruments have influenced scientific documentation size.
WHY IT MATTERS
The 2021 adjustments to the Facilities for Medicare and Medicaid Providers’ analysis and administration CPT billing codes aimed to scale back the executive documentation burden on suppliers, Epic Analysis stated in a brand new report.
To grasp if the adjustments had an impact, the researchers evaluated 1.7 billion scientific notes in digital well being information written by 166,318 outpatient suppliers throughout major care and specialties.
They discovered the suppliers averaged 4,628 characters per scientific notice in 2020 and elevated to a mean of 5,002 characters in 2023 (8%).
Nevertheless, suppliers usually diminished their common time of 5.4 minutes spent on every notice to 4.8 minutes per notice throughout the identical interval.
Whereas general common notice size elevated in the course of the examine interval, roughly 40% of suppliers did cut back their notice size common. A full 10% of these suppliers spanned major care, inner drugs, surgical specialties, dermatology, cardiology, psychiatry and different specialties.
“This implies {that a} discount in notice size is achievable in almost any specialty,” researchers stated.
“Moreover, almost 90% of suppliers diminished the common time they spent writing every notice.”
composition strategies, the Epic researchers additionally decided that healthcare organizations that diminished their use of SmartTools – documentation instruments that make it simple so as to add further content material to notes from different locations – and minimized copying and pasting inside the affected person chart additionally diminished their common notice size.
THE LARGER TREND
Final 12 months, researchers from the College of Pennsylvania Perelman College of Drugs in Philadelphia printed a JAMA examine about their work utilizing synthetic intelligence to research all UPenn Well being System notes over a five-year interval ending in 2020.
Pure language processing discovered a preponderance of duplication throughout all of the notes for 1.96 million distinctive sufferers. Half of the words were duplicated from prior notes, and the longer the document, the better the diploma of duplication.
This earlier examine concluded the time-based and author-based group of contemporary EHRs drive the prevalence of notice duplication.
“Duplicate textual content casts doubt on the veracity of all data within the medical document, making it tough to search out and confirm data in day-to-day scientific work,” the researchers stated.
Lately, Epic and Nuance announced new clinical documentation features combining conversational and ambient AI with GPT4 to show supplier and affected person conversational interactions into scientific documentation suppliers can edit and approve.
“This collaboration will permit our physicians to focus extra utterly on the care and therapy of their sufferers whereas the AI works behind the scenes to doc the encounter, permitting individuals and know-how to every do what they do greatest with out delays,” stated Dr. Hal Baker, CDIO at WellSpan Well being, in an Epic assertion in regards to the new utility.
ON THE RECORD
“Organizations that elevated notice size noticed secure use of SmartTools and elevated use of copy/paste capabilities,” the researchers stated within the report.
“These findings align with earlier analysis that discovered elevated use of SmartTools and duplicate/paste capabilities have been correlated with longer notes.”
Andrea Fox is senior editor of Healthcare IT Information.
Electronic mail: afox@himss.org
Healthcare IT Information is a HIMSS Media publication.
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