EPtalk by Dr. Jayne 7/13/23

I’ve been surprised by how much conversation I’ve heard about this Epic study in the virtual physician lounge. One of the key purposes of the study was to look at trends in documentation over the time period since CMS made updates to the way physicians can code their office visits. I’ve been surprised to learn how few physicians understand that changes happened – and those that understood that something changed are often unable to articulate how those changes have impacted their documentation. The majority of physicians discussing it share the “nobody told me” narrative, which I struggle to believe is as common as people say.

The largest physician specialty organizations ran article after article about these changes when they happened, as did national multispecialty organizations like the American Medical Association. The health system where I was working at the time had a major educational campaign around this, in part because they hypothesized that physicians would be able to bill higher codes under the new paradigm. There was a lot of chatter about it, but of course this conversation was during the height of the COVID pandemic and I’m sure a lot of us failed to fully understand a lot of things that came across our desks and inboxes during that time frame. For those of you who haven’t seen the study, here’s the highlight reel: Although the time to create clinical notes has decreased, the average length of those notes continues to increase.

While it’s great that notes have taken less time to document, the persistence of longer notes continues to contribute to the problem. It still takes time for recipients to read those lengthier notes, and the impact is compounded the larger the size of the care team. Another interesting factor called out in the study’s key findings is the fact that, “while overall average note length increased, around 40% of providers reduced their average note length.” That means that 60% of providers had the same notes, with some of them having longer, so that the math for the average works out. In my clinical work, I still see plenty of bloated communications from other providers and wish they had the personal drive or institutional support to streamline their documentation.

A reader alerted me to this article that falls squarely in the column of “physicians behaving badly.” A North Carolina otolaryngologist was sentenced to 25 years in prison for committing Medicare fraud by reusing single-use surgical devices. Although she performed more than 1,400 sinus surgeries over a seven-year period, she was only able to provide records of having purchased 36 of those devices. She billed Medicare more than $46 million for the procedures, which most certainly would have raised red flags. Patients impacted by the fraud will have 90 days to present claims for damages. This kind of behavior is horrific and egregious and contributes to the rising distrust of patients felt by many physicians these days. I hope she spends the next couple of decades reflecting on the situation.

Last week, I commemorated the passing of July 1, which is the traditional day in the US that medical students start their internships and other medical trainees advance in their residency programs. I asked for people to share their best or worst memories of internship, and our readers did not disappoint. Dr. Nick van Terheyden shared a blog about his first days as a junior doctor. I was surprised to learn that there was little difference between his experiences in the UK during the 1980s and my experiences in the US in the 1990s. He also reminisced about some notes he came across when a hospital in London was being relocated. The notes were written during The Blitz and as much as we found practicing medicine stressful during the COVID pandemic, I can’t imagine trying to practice in the middle of an air raid.

One of my favorite correspondents shared the story of a July 4 night on call at a big city hospital. They were working in the emergency department but weren’t seeing a lot of patient volume, so their attending physician invited them to take a break to watch fireworks. The savvy attending had brought lawn chairs and led them up the secret stairs to the roof, where they had a great view of the city’s fireworks show.

Still, nothing beats the story of “interoperability” as it occurred in a hospital where the interns figured out how to liberate patient charts from the dialysis clinic when patients needed to be admitted to the hospital. Apparently the clinic had a divided “Dutch door” entrance and an enterprising intern figured out how to get the top half open without a key so they could consult the patient charts, write their notes, and return them before morning. It’s a good reminder of what life was like before electronic health records. I never had to climb into an office to grab a chart but I did spend a lot of hours in the medical records area digging through month-old, half-documented charts to try to make sense of them while I was in the process of readmitting recently discharged patients.

I’m a big fan of celebrating milestones, and today marks the 1,300^th post I’ve written for HIStalk. It’s been a bit of a long, strange, trip. I started writing during the incentive-hungry boom created by the Meaningful Use program. Since then, the world of healthcare information technology has been through numerous ups and downs, including periods of wild growth and unbelievable scarcity. Still, I’m impressed every day by the physicians that continue to put their scrubs on one leg at a time and care for patients despite the frustration and hardships found in the practice of medicine today. I’m continually grateful for the IT professionals that support them and make sure the servers are humming, the desktops are cooperative, and that they have the access they need to take care of people. And to all the others who support patient care – be it housekeeping, nutrition, engineering, or the dozens of other departments – we salute you.

How do you like to celebrate milestones? Leave a comment or email me.

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