Improved Medical Student Engagement with EHR Documentation following the 2018 Centers for Medicare and Medicaid Billing Changes

Abstract

Background Medical student note writing is an important part of the training process but has suffered in the electronic health record (EHR) era as a result of student notes being excluded from the billable encounter. The 2018 CMS billing changes allow for medical student notes to be used for billable services provided that physical presence requirements are met, and attending physicians satisfy performance requirements and verify documentation. This has the potential to improve medical student engagement and decrease physician documentation burden. Methods Our institution implemented medical student notes as part of the billable encounter in August 2018 with support of our compliance department. Note characteristics including number, type, length, and time in note were analyzed before and after implementation. Rotating medical students were surveyed regarding their experience following implementation. Results There was a statistically significant increase in the number of student-authored notes following implementation. Attending physicians' interactions with student notes greatly increased following the change (4% of student notes reviewed vs. 84% of student notes). Surveyed students reported that having their notes as part of the billable record made their notes more meaningful and enhanced their learning. The majority of surveyed students also agreed that they received more feedback following the change. Conclusion Medical students are interested in writing notes for education and feedback. Inclusion of their notes as part of the billable record can facilitate their learning and increase their participation in the note writing process.

Using event logs to observe interactions with electronic health records: an updated scoping review shows increasing use of vendor-derived measures

“… 11 Aims were not mutually exclusive so each study could have more than 1 aim. While all vendor-measure studies measured an amount of EHR use (e.g., volume or duration), 2–4 , 6 , 19 , 24–58 a third (33%) of investigator-measure studies did not, 60 , 68 , 74 , 78 , 80 , 82–87 , 89 , 91 , 92 , 98 , 102 , 109 , 112 , 115 focusing instead on the other 2 aims ( P < .001). Vendor-measure studies were more likely to characterize EHR or clinical workflows , such as when EHR activities were performed during the day (68% vs 43% of articles, P = .016), while investigator-measure studies were more likely to characterize team dynamics , for example, using record coaccess to determine which clinicians routinely worked together (23% vs 3% of studies, P = .004).…”

“…While vendor-measure studies only ever included physicians or advanced practice providers (APPs), a third of investigator-measure studies (34%) included all EHR users who performed the observed activity, 73–76 , 84–90 , 103–108 , 115–118 and another 11% specifically included nurses, medical students, or scribes. 77 , 91–95 , 109 Vendor-measure studies were more likely to include data from multiple institutions (25% vs 8% of studies, P = .025) and to observe overall EHR use, rather than only collect data on a specific activity such as note writing or inbox management (98% vs 48% of studies, P < .001). The median number of participants (201 vs 172, P = .08) and organizations observed (1 vs 1, P = .42) were not significantly different between vendor-measure and investigator-measure studies.…”

“… 97 Three observational studies predicted patient-provider relationships based on EHR use. 82 , 98 , 103 Ten observational studies were longitudinal, comparing EHR use at different points in time including before and after the start of the coronavirus disease 2019 (COVID-19) pandemic, 2 , 3 , 34 , 37 , 89 before and after a change to the EHR interface, 107 before and after policy changes, 101 , 109 and at different points of clinical training. 32 , 52 The 11 experimental studies examined the impact of scribes, 30 , 41 , 111 EHR training, 38 , 45 , 54 , 119 and interface changes on EHR use.…”

“…Looking at specific measures of EHR use reported in each study reveals additional differences, particularly regarding durations of EHR use ( Figure 4 ). Reported time-based measures included total time in the EHR (49 articles), 3 , 4 , 19 , 24–33 , 35–49 , 51–59 , 61 , 66 , 69–73 , 77 , 79 , 95 , 98 time in notes (32 articles), 3 , 4 , 7 , 19 , 24–32 , 35–38 , 40–46 , 48 , 51 , 55–58 , 79 , 109 time in inbox (23 articles), 2–4 , 19 , 24 , 25 , 27–29 , 35–38 , 42 , 43 , 45 , 47 , 48 , 51 , 61 , 62 , 70 , 71 time in chart review (23 articles), 3 , 4 , 24–27 , 29 , 31 , 32 , 35 , 36 , 40 , 42 , …”

The Lost Art of Documentation*

“…In fact, one study revealed that 37% of medical students from multiple training programs were not allowed to document during one of their clerkships (18). Notably, the "Patients over Paperwork" initiative has led to an increase in review of medical student notes by attending physicians as well as a more meaningful learning experience for students (19). Not only does this acknowledge the value of medical students within the healthcare system, but it also teaches them an important skill.…”