The evolution of medical record documentation
Dermatologists discuss how a changing medical documentation process has affected physician burden and patient care.
Feature
By Allison Evans, Assistant Managing Editor, November 1, 2024
The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication. However, over time additional requirements have been placed on the clinical documentation process for purposes other than guiding and improving patient care. EHRs have led to further changes in the clinical documentation process, adding distinct advantages as well as new complexities and challenges.
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Key takeaways from this article:
The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication. Over time, additional requirements have been placed on the clinical documentation process for purposes other than guiding and improving patient care.
The SOAP (subjective, objective, assessment, plan) note was first introduced into medicine in the 1970s. At the time, there was no standardized process for medical documentation.
Medical documentation now serves multiple needs and, as a result, the notes have expanded in length and breadth compared to 50 years ago.
During the time of paper documentation, notes were decidedly simpler and more personalized. Medical documentation has now transitioned to a more narrative approach.
The focus on entering increasing amounts of data into EHRs to check all the boxes has led to an epidemic of physician burnout.
The 1995 and 1997 E/M coding guidelines implemented by CMS required a greater volume of documentation. The focus of documentation is now primarily medicolegal and billing.
Many dermatologists are likely already utilizing digital assistant augmented intelligence (AuI) programs in their practices. AuI and artificial intelligence (AI) have shown some promising potential with administrative burden in health care, particularly around clinical documentation.
A brief history
Cave paintings created 17,000-15,000 years ago uncovered in southwestern France showed an injury of a man attacked by an animal. Some consider this pictogram the first medical record (https://doi.org/10.3390/biomedicines10102594).
Patient records have been around for over 4,000 years. Medical records, as we know them, were first developed in Paris and Berlin during the 1800s. However, they only became useful for daily patient care in hospitals and clinics during the 1900s.
By the 20th century, documentation became wildly popular and was used throughout the nation after physicians realized that they were better able to treat patients with a complete and accurate medical history. Health records were soon recognized as being critical to the safety and quality of the patient care experience.
Paper medical records were steadily maintained from the 1920s onward, but the advancing technology of the ‘60s and ‘70s encouraged some American universities to explore how medical records and computers could operate together. In the early 1960s, the Mayo Clinic in Rochester, Minnesota, was one of the first major systems to adopt an EHR.
Tighter regulations regarding meaningful use of EHRs have resulted in more physicians adopting EHR systems from 2009 onward.
A simpler note
The SOAP (subjective, objective, assessment, plan) note was first introduced into medicine in the 1970s. At the time, there was no standardized process for medical documentation. It was the initial users of SOAP notes who were able to retrieve patient records for a given medical problem the fastest.
During the time of paper documentation, notes were decidedly simpler. “A patient comes in with a rash. I see plaques on their elbow. My assessment is that it’s psoriasis, and I’m going to prescribe a topical cream. That was what notes used to be like. They were often five or six sentences,” said Tom Helm, MD, FAAD, professor of dermatology at Penn State University and dermatologist at Penn State Health.
Aaron Farberg, MD, FAAD, a double board-certified dermatologist and fellowship-trained Mohs surgeon, agreed. “It was much more simplified and to the point on paper. It was also more focused on physician communication and notetaking. When you see a patient back in a year and want to know what you’re doing, what you’re watching, what did I do the last time — it was right there often on one page,” he said.
“When I left training, I hired a transcriptionist,” Dr. Helm said. “We used a dot matrix printer. I would use a personal hand-held recorder, she would listen to the tape and type the note, I would make any edits, and we would literally paste it on the paper. I’ve seen everything from index cards to a doctor using a Smith Corona typewriter to make his notes prior to computerization.”
Notes were often more personalized, Dr. Helm added. “Personal information about patients, their families, and other items helped build a connection between patients and their physician when they had a return visit. There was more emphasis on getting to know the person. ‘Daughter, Sally, is in the fifth grade. Son won 3rd place in the school swim meet. Jimmy got a scholarship.’ Now, there is no great place to put this kind of information in the chart and some suggest it is inappropriate to add information of this type to an objective record. Requirements for billing were very different too.”
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Telling a story
Over the years, medical documentation has transitioned to a more narrative approach, said Faith McNicholas, the Academy’s manager of coding and reimbursement. “Now, we’re telling a story. We talk about the patient’s history, diagnosis, present the findings based on the patient’s history, and then indicate what the plan of care is going to be going forward.”
At the same time, charts have become much more formulaic, Dr. Helm said. “While it can make people meet certain minimum requirements, it can also be limiting for physicians who are exceptional at connecting with patients.”
Medical documentation now serves multiple needs and, as a result, the notes have expanded in both length and breadth compared to 50 years ago. “The cause of the gradual shift in documentation is really insurance edicts, including Medicare documentation requirements, which influenced what needed to be recorded,” said Alex Miller, MD, FAAD, who is in private practice in Yorba Linda, California, and represents the American Academy of Dermatology on the AMA-CPT Advisory Committee.
The older SOAP documentation style was similar to a template, said McNicholas. “You check boxes, and half of the boxes didn’t make sense to the patient you were treating, so it wasn’t communicating correctly to the payer. As a result, we used to see a lot of audits because the medical record documentation didn’t support the diagnosis and CPT code for the services provided because of lacking information in the documentation.”
Also, from a medical malpractice standpoint, the concept of medical records shifted to the assumption that if something wasn’t documented, it didn’t occur. “One had to start documenting in a more granular fashion,” Dr. Miller said. “And while more data may be a wonderful thing, there have been no decisive papers pointing to the fact that this additional material being charted has actually led to better patient care.”
5 tips for optimizing clinical documentation
Electronic documenting is becoming increasingly burdensome for dermatologists. Check out these tips to help you spend less time charting and more time focusing on creating a work-life balance. For additional resources, visit the AAD Practice Management Center.
1. Train all practice staff and use their skills.
If your team members have expertise in documenting during a patient visit, use it to your advantage! The medical assistant (MA) can review medications, patient medical history, or current symptoms while the physician chats with the patient. The physician can quickly review the information, answer any questions the MA has, and sign off on the note and any e-prescriptions needed right then and there in the room. This will ensure that the patient’s needs are heard right away, and all clinical notes can be taken care of in the exam room.
2. Be aware of current E/M services and other codes from AMA CPT.
Knowing these well will help ease documentation while filling out the patient’s chart. Check out the Academy’s E/M coding page to learn more about the components about coding the levels of E/M services.
Downloadable coding tip sheets provide convenient guidance on common coding for your practice.
3. Tap into your available basic EHR functions.
Templates are a more efficient way to record a patient’s condition that is commonly seen. These templates can be focused on specific measures, guidelines, or conditions that are already used in the office. They can be geared toward guidelines, protocols, pre- and post-procedural matters, and post-discharge requirements.
Manage problem lists: Create and maintain patient-specific problem lists that can be easily captured during visits, which can increase clinical workflow efficiency and improve clinical decision-making.
Manage patient history: During every exam visit, capture and review the patient’s medical history to help diagnose new conditions in the future.
4. Time yourself on how long it takes to complete a note.
If you know your baseline, you can set reasonable expectations on how long it will take to document. You can also set goals for improving efficiency. Identifying problem areas can spur improvements to existing templates that reduce documentation burdens.
5. Consider getting a scribe or using voice recognition software.
These tools have proven successful in reducing physician frustration regarding electronic documentation. A variety of in-room scribes, e-scribes, and voice recognition tools are available to increase efficiency. Learn more.
EHRs
The process of medical documentation has changed dramatically since the development of the electronic health record. The U.S. government introduced the Meaningful Use program as part of the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act to encourage physicians and non-physician providers to show “meaningful use” of a certified EHR system in order to receive full reimbursement from Medicare. Despite the federal government propelling the adoption of EHRs, obstacles remain regarding cost, standardization, interoperability, time-consuming data entry, and security.
Time
The 1995 and 1997 evaluation and management (E/M) coding guidelines implemented by CMS required a greater volume of documentation, said Erin Gardner, MD, FAAD, FACMS, a double board-certified dermatologist and fellowship-trained Mohs surgeon, and former chair of the AAD’s EHR Task Force. “Even on paper, documentation became more extended. Once electronic documentation came along, it opened the door to these comprehensive software paradigms that could have every single possibility that one could imagine. It was at this point that documentation became a remarkable burden.”
Meeting the metrics of the medical record takes a substantial part of a physician’s day. In Dr. Helm’s intern year at the Cleveland Clinic in 1988, they still used paper charting. “I remember there would be a dermatology section in the paper chart, and it was pretty easy to find my old note and see what the key points were in the assessment and plan and move ahead. Now, in my electronic record, I need to click on a bunch of different things to access the same kind of information whereas before I could just scan through it.”
“It has become a job to manually enter data,” agreed Dr. Farberg. “On paper, if you were going to give a steroid injection, you’re not going to write out all the risks, benefits, and alternative treatment options discussed. I used to write ‘risks, benefits, and alternatives discussed.’ But the computer allows you to utilize preset documentation so you can enter a phrase that brings up a whole paragraph of information that isn’t really necessary for me to figure out what I need to do,” he said.
“My medical assistants act as scribes and they document all the things the patient is telling me and put in the basic assessment and plan, but then I go back in and write my own paragraph that has the information that really matters to me, so I don’t have to filter through five, six, seven pages,” Dr. Farberg said.
Checking boxes
“EHR companies have tried to minimize the need for any kind of writing and optimize hitting the landmarks for billing,” said Meyer Horn, MD, FAAD, a dermatologist in Chicago and clinical instructor of dermatology at Northwestern’s Feinberg School of Medicine. “Now, we worry about whether we’re talking about enough things and whether we can justify a particular billing level.”
“Without a doubt, things have become more complex,” Dr. Helm said. “There are so many more clicks. It has really pushed people away from the patient-centered encounter, which is the heart of medicine.”
This focus on entering increasing amounts of data to “check all the boxes” has added to the epidemic of physician burnout. “If you’re a people-person and now you’re spending half your day in front of a screen, that’s probably not going to bring you joy,” Dr. Helm said.
‘Note bloat’
“Electronic health records have made defensive documentation easier, which some would interpret as better documentation and others would interpret as a source of ‘note bloat,’ in which key findings and actions are obscured by superfluous negative findings, irrelevant documentation, and differential diagnoses, all of which make the record difficult and time-consuming to read,” according to a paper published in the Annals of Internal Medicine.
Because prior entries are easily carried forward to current notes, these bloated and distended records can be a source of excess downstream documentation that can make it difficult for physicians to quickly find what they need. “What I’m seeing is that people are cutting and pasting from prior notes, like the review of systems, and then just adding to that, which makes it harder to sift through and find what’s important or essential,” Dr. Helm said.
For example, each note will have a full medication list. “I don’t really need to know the dosage and frequency of the eye drops the ophthalmologist is prescribing. There is a lot of information that’s repeated over and over, so you have to sift through the information for the key features,” Dr. Helm said.
Coding Resource Center
Find practical tips, tools, quizzes, and videos about common dermatologic coding issues. Visit the Coding Resource Center.
New regulations
In 2021, CMS implemented new regulations, designed to reduce administrative documentation burdens associated with E/M CPT billing codes. The changes were intended to move documentation for E/M office visits to center around how physicians think and take care of patients, instead of on mandatory standards that encourage copy and paste and checking boxes. Now, a medically appropriate history and/or physical examination are no longer required to select the level of service, which have historically added “fluff” to clinical notes, according to the Journal of AHIMA (American Health Information Management Association).
A team of EPIC researchers conducted a study to determine if the legislative changes had the desired effect on clinical notes. The team evaluated 1.7 billion clinical notes written by 166,318 outpatient physicians and non-physician providers in EPIC EHRs in the United States from May 2020 to April 2023 to determine the average length in characters for each note. They found that the average note length across all clinical notes had increased 8.1%, the opposite of the new regulation’s intent.
The researchers suspected that physicians are still writing longer clinical notes because they are adhering to the 1995/1997 guidelines that required clinicians to provide extensive documentation to get paid by insurers. Many physicians might still be leery of adopting the newer 2021 regulations, as they worry that payers are not going to accept the new, shorter notes.
Upsides
What nearly all dermatologists can agree upon is that the ability to easily add images to the record has been a game-changer for medical documentation for dermatologists, in particular. “I have an app where my smartphone captures the image and puts it directly into the medical record,” Dr. Helm said.
“In the past, we took Polaroids or digital photographs, and then had to upload them and use a laborious linking process. It is so much easier than it used to be,” Dr. Gardner said.
“Whether documenting baseline stage of a disease or where a mole or skin cancer is, or capturing pictures of products patients may be using, it’s great because the images are immediately in the patient’s chart,” Dr. Horn said.
Additionally, EHR systems have helped make coding more audit-proof, said Eliot Mostow, MD, MPH, FAAD, head of the dermatology section at Northeast Ohio Medical University, department of internal medicine, and on the clinical faculty at Case Western Reserve University department of dermatology. “If you document what you did, the system captures the code. The system provides suggestions on the code, but you ultimately have to decide whether the code is accurate or not and sign off on that.”
“It also gave you really accurate ways of knowing how many reviews of systems you covered and how many chief complaints you had. As it turns out, those aren’t important anymore,” he added. “Now it’s the level of decision making and complexity of what you’re doing.”
Artificial and augmented intelligence in dermatology
Find out where things currently stand with machine learning — and what the future holds.
The future
“There is no question that computers have slowed us down,” Dr. Farberg said. “Now we’re trying to use technology to figure out ways to utilize computers to help speed us back up again.”
Dr. Helm uses an app where he dictates into his phone, and it shows up in the medical record. ‘I really like that because it allows me the opportunity to put in free text.”
Speech recognition software has had significant advances over the years, Dr. Gardner said. “I think it’s one of the keys to further reducing physician burden so that physicians become less of the clerical work horse.”
Many dermatologists are already likely using digital assistant augmented intelligence (AuI) programs in their practices. AuI and artificial intelligence (AI) have shown some promising potential with administrative burden in health care, particularly around clinical documentation in EHRs, said McNicholas, although there is still much to be ironed out.
According to an Academy augmented intelligence survey, members agree there is a need for AuI applications to assist more in administrative routine tasks such as documentation, clinical notes, coding, quality measurement reporting, and alleviating administrative burdens.
A study published in Future Healthcare Journal found that using AI tools significantly improved documentation quality and operational efficiency. On average, a consultation was found to be shorter in length by 26.3%, although this gain in time didn’t impact the physician-patient experience. In fact, patients and clinicians reported that it enhanced their interaction. “The more we use AI, the better it will be,” said McNicholas. “It learns from what we’re doing and keeps improving as we go. It will also ensure better compliance, so we have fewer audits.”
“I think where we probably encounter augmented intelligence is through our administrative tasks. For example, it can be used in documentation, with the help of natural language processing technology,” said Ivy Lee, MD, FAAD, deputy chair of the Academy Augmented Intelligence Committee, in a previous DermWorld article. “If I can apply machine learning in other aspects of delivering care — running an office, coding, scheduling, triaging messages, and charting — I think that would improve my efficiency and gift me more time and energy to be a better physician for my patients,” she said.
“Unfettered innovation across the various software programs is essential,” Dr. Gardner said. “A one-size-fits-all approach is never going to be good for clinical care or physicians because dermatologists don’t document like radiologists or pathologists or gynecologists.”
