Epic research shows note bloat has increased by 8%

Published Thursday by Epic Research, a dual-team study of notes written by 166,318 outpatient providers in the US from May 2020 to April 2023 examined how coding requirements and documentation tools affected the length of clinical documentation.

why it matters

The 2021 change in Medicare and Medicaid services evaluation and management CPT billing code centers is intended to reduce the administrative documentation burden on providers, Epic Research said in a new report.

To understand whether the changes had an effect, researchers evaluated 1.7 billion clinical notes in electronic health records written by 166,318 outpatient providers across primary care and specialties.

They found that providers created an average of 4,628 characters per clinical note in 2020 and increased to an average of 5,002 characters in 2023 (8%).

However, providers typically reduced the average time spent on each note from 5.4 minutes to 4.8 minutes per note during the same period.

While the overall average length of the note increased during the study period, approximately 40% of providers decreased the average length of their notes. A full 10% of those providers provided primary care, internal medicine, surgical specialties, dermatology, cardiology, psychiatry, and other specialties.

“This suggests that note length reduction can be achieved in almost any specialization,” the researchers said.

“In addition, nearly 90% of providers reduced the average time spent writing each note.”

Looking at structuring methods, EPIC researchers also determined that healthcare organizations reduced the use of SmartTools – documentation tools that make it easier to add additional content to notes from other places – and increased copying and pasting within patient charts. The reduction also resulted in a reduction in their average note length.

big trend

Last year, researchers at the University of Pennsylvania Perelman School of Medicine in Philadelphia published a jama Study about their work using artificial intelligence to analyze all UPN Health System notes over a five-year period ending in 2020.

Natural language processing found a predominance of repetition across all notes for 1.96 million unique patients. Half of the words were repeated from prior notes, and the longer the record, the greater the degree of repetition.

This earlier study concluded that the time-based and author-based organization of modern EHRs increases the prevalence of note duplication.

“The duplicate text casts doubt on the veracity of all information in the medical record, making it difficult to find and verify information in day-to-day clinical work,” the researchers said.

Most recently, Epic and Nuance announced new clinical documentation features, combining conversational and ambient AI with GPT4 to transform provider and patient interactions into clinical documentation that providers can edit and edit. Can approve

“This collaboration will allow our physicians to fully focus on the care and treatment of their patients, while AI works behind the scenes to document the encounter, allowing people and technology to connect,” said Dr. Hal. Allowing you to do your best work without delay.” Baker, CDIO of Welspan Health, in an epic statement about the new application.

On the record

“Organizations that increased note length showed steady use of smarttools and increased use of the copy/paste function,” the researchers said in the report.

“These findings are consistent with previous research that found increased use of smarttools and the copy/paste function were correlated with longer notes.”

Andrea Fox is a senior editor for Healthcare IT News.
Email: afox@himss.org
Healthcare IT News is a HIMSS Media publication.