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Other Epic Dataset

Two Years After Coding Changes Sought to Decrease Documentation, Notes Remain ‘Bloated’

July 6, 2023
Dual-Team Study
Team A: Kersten Bartelt, RNBrendan JoyceKyle McCaffrey
Team B:Sam Butler, MDJoe Deckert, PhDChris Gates

Key Findings

  • The average length of clinical notes has continued to increase over the last three years despite coding changes enacted in 2021 meant to reduce documentation burden.  
  • However, time spent writing notes by providers has slightly decreased over the same time.  
  • While overall average note length increased, around 40% of providers reduced their average note length.  

In 2021, the Centers for Medicare and Medicaid Services (CMS) implemented changes to evaluation and management (E/M) CPT billing codes aimed to reduce the administrative documentation burden on providers.1 A study looking at early outcomes related to these changes from January to April 2021 did not observe any decrease in note length.2 Now that the E/M coding changes have been in place for more than two full years, we wanted to understand whether there has been any influence on documentation length.  

We evaluated 1.7 billion clinical notes written by 166,318 outpatient providers in the U.S. from May 2020 to April 2023 to determine the average length in characters for each note. We found that the average note length across all clinical notes has increased 8.1%, from 4,628 characters in May 2020 to 5,002 characters in April 2023, as shown in Figure 1.  

Figure 1
Average Note Length Over Time
Average Note Length Over Time
Figure 1. Average length of notes in characters from May 2020 to April 2023. 

However, despite these increases in note length, the average time spent writing notes decreased 11.1% over this same period, from an average of 5.4 minutes per note to 4.8 minutes per note. Additionally, providers are spending less time in clinical review activities in the EHR. 

We then compared each provider’s average note length in 2020 to that same provider’s average note length in 2023. We stratified providers into deciles based on how much their average note length changed during that time and found that about 40% of providers decreased their average note length over those three years, as shown in Figure 2. Additionally, we found that the 10% of providers who decreased their note length the most represented a wide variety of specialties including primary care, internal medicine, surgical specialties, dermatology, cardiology, and psychiatry. This suggests that a reduction in note length is achievable in nearly any specialty. Furthermore, nearly 90% of providers reduced the average time they spent writing each note. 

Figure 2
Change in Average Note Length and Change in Time Spent per Note by Provider
Change in Average Note Length and Change in Time Spent per Note by Provider
Figure 2. Average change in length of note in characters and minutes spent in notes by provider from May 2020 to April 2023 broken into deciles.

We also studied whether there had been changes in the ways notes were written over time and whether those composition methods correlated with longer or shorter notes. We found that organizations that reduced their use of SmartTools—documentation tools that make it easy to add additional content to notes from other places in the patient’s chart—and copy/paste functions also reduced their average note length. Conversely, organizations that increased note length saw stable use of SmartTools and increased use of copy/paste functions. These findings align with previous research that found increased use of SmartTools and copy/paste functions were correlated with longer notes.2 

Figure 3
Composition Methods and Influence on Organizational Note Length
Composition Methods and Influence on Organizational Note Length
Figure 3. Average change in use of various note composition methods for organizations that increased or decreased their average note length by at least 5% over the study period.

Even though average note length increased, most providers spent less time writing notes, which could help providers free up time for patient care or reduce work after hours. Previous studies suggest there may be other benefits to the E/M changes that influence a provider’s well-being, such as reducing cognitive burden or increasing physician efficiency with documentation.3,4 

These data come from Signal, which aggregates Epic EHR use data for providers across 384 organizations. This study was completed by two teams that worked independently, each composed of a clinician and research scientists. The two teams came to similar conclusions. 

References

  1. Centers for Medicare and Medicaid Services. Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019 | CMS. Accessed on June 6, 2023. 
  2. Apathy NC, Hare AJ, Fendrich S, Cross DA. Early Changes in Billing and Notes After Evaluation and Management Guideline Change. Ann Intern Med. 2022;175(4):499-504. doi:10.7326/M21-4402 
  3. Apathy NC, Rotenstein L, Bates DW, Holmgren AJ. Documentation dynamics: Note composition, burden, and physician efficiency. Health Serv Res. 2023;58(3):674-685. doi:10.1111/1475-6773.14097 
  4. Maisel N, Thombley R, Overhage JM, Blake K, Sinsky CA, Adler-Milstein J. Physician Electronic Health Record Use After Changes in US Centers for Medicare & Medicaid Services Documentation Requirements. JAMA Health Forum. 2023;4(5):e230984. doi:10.1001/jamahealthforum.2023.0984