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Cited by 4Electronic Health Records SystemsMedical Coding and Health InformationHealthcare Policy and Management

CMS Payment Policy, E&M Guideline Reform, and the Prospect of Electronic Health Record Optimization

Open access
Basch, Peter, Smith, Jeffery·2018·Applied Clinical Informatics
DOI 10.1055/s-0038-1676337PMC PMC6306276
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Abstract

The potential for the widespread use of electronic health records (EHRs) to improve the quality and safety of health care was a key theme of the Institute of Medicine's seminal report of 2001, “Crossing the Quality Chasm.”[ 1 ] EHRs were envisioned as infrastructure to a better systems-level approach to health care delivery, leveraging information technology (IT) functionality, such as point-of-care order entry and clinical decision support. This groundbreaking report further anticipated two levers that would make the capabilities within EHRs more likely to be consistently used for the purposes of care improvement—payment policy and efficiency. It was understood that clinician payment would need to move from just paying for procedures and services, to also paying for the enhanced use of health information to improve outcomes.[ 2 ] And it was assumed that operational efficiency, an intrinsic capability of mature IT seen in all other sectors, would also be seen in health care. The idea was that if physicians and other clinicians could be induced or incented to purchase and use EHRs, everyday time-consuming “paperwork” burdens would greatly diminish (or disappear!); and supported by payment policy, clinicians would make use of this new found time to focus on improving quality and safety, and perhaps even doing their part to make care more affordable. Fast forward to 2018, and at least part of that vision is bearing fruit. While the evidence is mixed, there exists a reasonable argument for thoughtful use of EHRs resulting in better and safer care.[ 3 ] However, there is scant evidence that use of EHRs has made health care delivery more efficient; to the contrary—the pre-EHR complaint of “I spend more time on paperwork than I do with patients” has been replaced with an even louder cry of “I spend more time with my EHRs than I do with patients.”[ 4 ] In fact, physicians now perceive EHRs as the cause of—not a solution to—inefficiency, and the primary cause of physician burnout.[ 5 ] [ 6 ] [ 7 ] What happened? Implementation of IT in fields other than health care have shown (after a period of training and workflow adjustment) efficiency gains for technology end-users.[ 8 ] Similar efficiency gains were assumed after the implementation of an EHR. However, persistent inefficiency in health care operations continues despite EHR implementation due to friction from two preexisting conditions: administrative or “paperwork” burdens—such as formulary adherence and prior authorizations—and the regulatory burden of documentation for payment purposes (the Evaluation and Management Documentation Guidelines [E&M Guidelines]). Two new areas of burden further exacerbate health care inefficiency, including regulatory burden associated with specific documentation for incentive and/or quality programs, and what can be called “EHR burden”—burden resulting from poor design and usability, suboptimal implementation, and inadequate training. The proposed 2019 Medicare Physician Fee Schedule[ 9 ] (PFS) represents the first time the Trump administration has sought to imprint its deregulatory ethos toward Centers for Medicare and Medicaid Services (CMS) payment policy at scale; with leadership at the Department of Health and Human Services (HHS) signaling a continuation of value-based care and a refocusing on both quality “measures that matter,”[ 10 ] and the placing of “patients over paperwork,”[ 11 ] as top priorities. Key among proposed changes in the PFS is a streamlining of the existing E&M Guidelines. This commentary will explore how a reduction in regulatory documentation burden, through E&M Guideline reform, could favorably impact clinicians' use and interaction with EHRs, and in turn, improve the doctor–patient relationship. This commentary will not address one of the more controversial components of this proposed rule—that of creating leveling payment for outpatient office visits. Protection of Human and Animal Subjects The authors certify that no human subjects were involved in development of this material.

AI snapshot

Written from the paper’s full text.

TL;DR

This commentary argues that Medicare’s Evaluation and Management documentation rules, rather than EHR technology alone, have driven clinical documentation burden and poor EHR usability. It assesses the 2019 Medicare Physician Fee Schedule proposal to simplify outpatient E&M documentation and predicts limited but positive effects if finalized and extended beyond Medicare outpatient services.

Key findings

  • The commentary says EHRs have not delivered the expected efficiency gains; clinicians increasingly perceive EHRs as a cause of inefficiency and burnout, with administrative, regulatory, and documentation burdens as key sources of friction.
  • It traces E&M Guidelines to 1995 and 1997 efforts to control coding increases; by 2001 the AMA and 38 other societies called the guidelines burdensome, confusing, and flawed, and a 2002 HHS advisory committee recommended discarding them. The 2003 Medicare Modernization Act called for pilots without those guidelines, but no pilots occurred.
  • It argues E&M rules created an EHR business case based on audit protection and higher coding, then contributed to overdocumentation and lengthy notes. A 2011 AMIA policy meeting and a 2015 AMA–ACP–EHRA usability summit concluded that reimbursement and documentation rules limited usability improvements.
  • The proposed 2019 Medicare PFS would allow outpatient E&M documentation via near-lowest-level guidelines, medical decision making, or time. The author expects less overdocumentation and more meaningful patient time, but notes the proposal does not eliminate E&M Guidelines and covers only Medicare outpatient E&M.

Methods

  • Narrative policy commentary and analysis, not an empirical study; no sample, dataset, or statistical analysis is reported.
  • It synthesizes policy history, prior literature, and the proposed 2019 Medicare Physician Fee Schedule, and includes an illustrative outpatient note and multiple-choice questions.
  • The paper certifies that no human or animal subjects were involved.

Limitations

  • Stated: the proposal must be finalized and is unlikely to be finalized without revision because of near-universal opposition to linking reduced documentation with level payment for office visits.
  • Stated: even if finalized, impact is limited because it addresses only Medicare outpatient E&M documentation; inpatient, emergency department, and private-payer changes would be needed, and reduced regulatory documentation only sets the stage for reducing EHR burden rather than guaranteeing it.
  • Evident: as a commentary without empirical data, it cannot quantify effects on documentation time, burnout, or usability; the example note is illustrative rather than validated.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1055/s-0038-1676337

Cites

19 of 19 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 19 cited sources checked · 0 supported · 0 flagged

  • Interpretationreasoning

    EHR functionality and continued audit fears led to widespread overdocumentation of unnecessary and redundant information as the new normal.

    “Worse, EHR functionality and continued audit fears led to widespread overdocumentation of unnecessary and redundant information as the new normal.”
    Quote in the paperSubstantial claim
  • Premisecitation

    The E&M Guidelines were seen by practicing clinicians as a distraction and another nonclinical encroachment on the little time they had with each patient.

    “The E&M Guidelines were seen by practicing clinicians as a distraction and another nonclinical encroachment on the little time they had with each patient.15”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [15] 15. Berenson RA, Basch P, Sussex A. Revisiting E&M visit guidelines-a missing piece of payment reform. N Engl J Med 2011;364(20): 1892-1895

      Not checked in the free run.

  • Premisecitation

    The E&M Guidelines never fulfilled their original purpose of controlling costs by dissuading code creep.

    “And it should not come as a surprise that E&M Guidelines never fulfilled their original purpose, which was to control costs by dissuading “code creep.”17”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [17] 17. Straightforward Medical Decision-Making. Available at: https:// emuniversity.com/StraightforwardMedicalDecision-Making.html. Accessed November 15, 2018

      Not checked in the free run.

  • Premisecitation

    The Medicare Modernization Act of 2003 called for CMS to conduct pilots of new approaches to pay for physician services without using the E&M documentation guidelines.

    “And shortly thereafter, the Medicare Modernization Act of 2003 called for CMS to conduct pilots of new approaches to pay for physician services, without using the E&M documentation guidelines.14”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [14] 14. Miller R, West C, Martin TB, et al. The Value of Electronic Health Records in Solo Or Small Group Practices. Health Affairs. Vol. 24, No. 5. Available at: https://www.healthaffairs.org/doi/full/10.1377/hlthaff. 24.5.1127. Accessed November 15, 2018

      Not checked in the free run.

  • Premisenone given

    The response of many practicing clinicians still using paper records was to shift from terse handwritten or dictated notes to preprinted templates or hybrid notes permitting an E&M-compliant note.

    “The response from many practicing clinicians (still using paper records) was to shift from terse and meaningful handwritten or dictated notes, to the use of preprinted templatespermitting an E&M-compliant note to be created with a combination of checkboxes and scratch outs; or a hybrid note which combined a few sentences of narrative text with preprinted forms.”
    Quote in the paperNot a substantial claim
  • May combine two claims. 15
  • Classified as probably not a substantial claim. 13

  • May combine two claims.

    Findingreasoning

    Unnecessarily lengthy clinical notes are common, taking extra time for both the note author and the note reader.

    “What is common is the existence of unnecessarily lengthy clinical notes-taking extra time for both the note author, and note reader.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisenone given

    The number of systems included in a review of systems differs by coding level, and not all encounters require a complete review of systems.

    “The number of systems included in a review of systems differs by coding level.All encounters do NOT require a complete review of systems.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisenone given

    E&M Guidelines are used by both public and private payers to determine the appropriate level of service (and thus payment) for most nonprocedural E&M services such as office, emergency department, and hospital visits.

    “The Evaluation and Management Documentation Guidelines are used by both public and private payers to determine the appropriate level of service (and thus payment) for most nonprocedural (evaluation and management) services, such as office visits, emergency department visits, and hospital visits.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    The primary business driver for EHRs since the mid-1990s has been to support coding for billing purposes.

    “the primary business driver for EHRs since the mid-1990s has been to support coding for billing purposes.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    The 2011 AMIA Policy Meeting concluded that there is a need to transform the way clinical care is captured and documented, but that reimbursement policies provide little incentive to explore alternative data capture or documentation practices.

    “the 2011 AMIA Policy Meeting focused on the future of clinical data capture and documentation, concluding that “there is a need to transform the way we capture and document clinical care,” but that reimbursement policies provide “little incentive to explore alternative data capture or documentation practices.”18”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [18] 18. Erickson SM, Rockwern B, Koltov M, McLean RM; Medical Practice and Quality Committee of the American College of Physicians. Putting patients first by reducing administrative tasks in health care: a position paper of the American College of Physicians. Ann Intern Med 2017;166(09):659-661

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    A 2015 AMA-ACP-EHRA Usability Summit concluded that EHRs could not fundamentally become more usable as long as the existing E&M documentation guidelines were in place.

    “A 2015 AMA-American College of Physicians-Electronic Health Record Association Usability Summit concluded further that EHRs could not fundamentally become more usable as long as the existing E&M documentation guidelines were in place.19”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [19] 19. Kuhn T, Basch P, Barr M, Yackel T; Medical Informatics Committee of the American College of Physicians. Clinical documentation in the 21st century: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med 2015; 162(04):301-303

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    Some EHRs, particularly those developed in the 1990s, were developed as a response to the issuance of the E&M Documentation Guidelines.

    “Some EHRs, particularly those developed in the 1990s, were developed as a response to the issuance of the E&M Documentation Guidelines.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    The E&M Guidelines compelled verbose and mostly meaningless clinician notes on paper; because those notes were rarely shared and mostly illegible, their burden was seen almost entirely as burden on the note writer.

    “To be clear, E&M Guidelines compelled verbose and mostly meaningless clinician notes on paper, but because they were rarely shared (and mostly illegible), their impact on burden was seen almost entirely as burden on the note writer.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisereasoning

    The PFS proposal would not eliminate the existing E&M Guidelines but provides two compelling alternatives that could provide impetus for widespread and dramatic changes to clinical note-taking and EHR usability.

    “While the PFS proposal would not eliminate the existing E&M Guidelines, it provides two compelling alternatives that could very well provide impetus for widespread and dramatic changes to clinical note-taking and EHR usability.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [9] 9. FR 35836. Medicare Program: Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY; 2019; Medicare Shared Savings Program Requirements; etc. Available at: https://www.federalregister.gov/d/2018-14985/p- 706. Accessed November 15, 2018

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    E&M University describes adherence to the guidelines for straightforward MDM as nearly impossible not to qualify for.

    “E&M University describes adherence to the guidelines for straightforward MDM as nearly impossible not to quality for it.21”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [21]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based).

    Premisenone given

    Prior to the release of the E&M Guidelines, EHRs appealed primarily to certain academic centers and technophile early adopters.

    “Prior to the release of the E&M Guidelines, EHRs appealed primarily to certain academic centers and technophile early adopters.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation
    § CMS Payment Policy, E&M Guideline Reform, and the Prospect of Electronic Health Record Optimization

    Physicians perceive EHRs as the cause of inefficiency and as the primary cause of physician burnout.

    “In fact, physicians now perceive EHRs as the cause of-not a solution to-inefficiency, and the primary cause of physician burnout.[5][6][7]”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [5] 5. Friedberg MW, Chen PG, Van Busum KR, et al. Research Report: Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. Santa Monica, CA: Rand Corporation; 2013

      Not checked in the free run.

    • cites [6] 6. Downing NL, Bates DW, Longhurst CA. Physician burnout in the electronic health record era: are we ignoring the real cause? Ann Intern Med 2018;169(01):50-51

      Not checked in the free run.

    • cites [7] 7. Khairat S, Burke G, Archambault H, Schwartz T, Larson J, Ratwani RM. Perceived burden of EHRs on physicians at different stages of their career. Appl Clin Inform 2018;9(02):336-347

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    HHS convened an Advisory Committee on Regulatory Reform, which recommended in August 2002 to dump the E&M guidelines.

    “Committee on Regulatory Reform, which recommended in August of 2002 to “dump” the guidelines.13”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [13] 13. Moran M. M.D.s may soon be free of current E&M guidelines. Psychiatric News 2002;37(15):2. Available at: https://doi.org/ 10.1176/pn.37.15.0002. Accessed November 15, 2018 14 Sec. 941 of the Medicare Modernization Act of 2003 15 Comments from Physicans Regarding AMA/HCFA. "E&M Docu- mentation Guidelines." Available at: https://www.aapsonline. org/surveys/emcommen.htm. Accessed November 15, 2018

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § CMS Payment Policy, E&M Guideline Reform, and the Prospect of Electronic Health Record Optimization

    By 2001, the AMA and 38 other medical professional societies labeled the E&M guidelines as burdensome, confusing, and flawed, calling them the single largest paperwork burden imposed by the Medicare program, and asked CMS to reevaluate their need and value.

    “By 2001, the American Medical Association (AMA) and 38 other medical professional societies labeled the guidelines as burdensome, confusing, and flawed, calling them “the single largest paperwork burden imposed by the Medicare program,” and asked the CMS to reevaluate their need and value.12”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [12] 12. Lehmann C. AMA protest convinces HHS secretary to review useful- ness of E&M guides. Psychiatric News 2001;36(16):4. Available at: https://doi.org/10.1176/pn.36.16.0004a. Accessed November 15, 2018

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

    Interpretationreasoning

    Leveraging the EHR to contain advanced visualizations of prior information and clinical notes was never a top priority because E&M Guideline-derived information was too bloated to be useful.

    “Leveraging the EHR such that it contained advanced visualizations of prior information and clinical notes was never a top priority, because E&M Guideline-derived information was too bloated to be useful.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning
    § CMS Payment Policy, E&M Guideline Reform, and the Prospect of Electronic Health Record Optimization

    Two new areas of burden further exacerbate health care inefficiency: regulatory burden associated with documentation for incentive and/or quality programs, and EHR burden resulting from poor design and usability, suboptimal implementation, and inadequate training.

    “Two new areas of burden further exacerbate health care inefficiency, including regulatory burden associated with specific documentation for incentive and/or quality programs, and what can be called “EHR burden”burden resulting from poor design and usability, suboptimal implementation, and inadequate training.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationreasoning

    Reducing regulatory documentation burden can only set the stage for an eventual reduction in EHR burden; it does not guarantee that reduction will occur.

    “And finally, reducing regulatory documentation burden can only set the stage for an eventual reduction in EHR burden-it does not guarantee it will occur.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

    Interpretationreasoning

    The EHR era has compounded clinician burden by several orders of magnitude while worsening the patient-doctor relationship.

    “Indeed, the EHR era has compounded clinician burden by several orders of magnitude, while worsening the patientdoctor relationship.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationnone given

    Many clinicians overdocument in many clinical notes because they cannot remember exactly what needs to be documented for a given level of service or because they fear failing an E&M coding audit.

    “Many clinicians, either because they cannot remember exactly what needs to be documented for any given level of service, or due to fear of failing an E&M coding audit, overdocument in many clinical notes.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    The introduction of EHRs made the same notes legible and easily mobilized to others, generating burden for both the note author and the note reader.

    “The introduction of EHRs made the very same notes legible and easily mobilized to others-generating burden to both the note author and reader.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisereasoning

    Failure to conform to the E&M documentation requirements carried the threat of civil and/or criminal penalties for billing fraud, so physicians took compliance seriously, adding more time to documentation.

    “And because failure to conform to these documentation requirements carried the threat of civil and/or criminal penalties for billing fraud-physicians took compliance with these guidelines seriously, adding even more time to what they had previously spent on medical documentation.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationnone given

    Clinicians trained after 1995 may not know better than to overdocument, because the primary arbiters of documentation shifted from clinical mentors to coders, auditors, and compliance officers.

    “Clinicians trained after 1995, when the primary arbiters of documentation shifted from clinical mentors to coders, auditors, and compliance officers, may not know any better.”
    Quote in the paperNot a substantial claim
22 of 22

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Questions regarding subjective burden and satisfaction in documentation practices remain unanswered.

    “Questions regarding subjective burden and satisfaction in documentation practices remain unanswered.”

    From Effect of an Electronic Health Record-Based Intervention on Documentation Practices (2024) · cites this paper as [14]

    In “Will Documentation Burden Decrease as a Result of This Proposal?” (page unavailable), the authors say the effect of proposed reforms on documentation burden “remains to be seen.” They do not address whether questions about subjective burden or satisfaction with documentation practices remain unanswered more generally. (LLM, conf=0.78)

    Experimental — accuracy not yet measured

  • The 2021 Evaluation and Management (E&M) coding changes were implemented to alleviate documentation burden.

    “Evaluation and Management (E&M) coding changes were implemented in 2021 to alleviate documentation burden.”

    From Effect of an Electronic Health Record-Based Intervention on Documentation Practices (2024) · cites this paper as [14]

    The paper’s discussion of the proposed 2019 Medicare Physician Fee Schedule says E&M guideline reform was intended to reduce regulatory documentation burden. In “Will Documentation Burden Decrease as a Result of This Proposal?” (page unavailable), the authors say the proposal had yet to be finalized. The paper therefore supports the stated aim, but not the claim that changes were implemented in 2021. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

Cites

Flagged first, then by citations

Research works printed but not linked: 1

  1. [7]7. Khairat S, Burke G, Archambault H, Schwartz T, Larson J, Ratwani RM. Perceived burden of EHRs on physicians at different stages of their career. Appl Clin Inform 2018;9(02):336-347

Cited by

Sorted by citations

Related

Authors
Basch, P., & Smith, J.
Affiliations
  • MedStar Health (US)
  • American Medical Informatics Association (US)
Corresponding author
Smith, Jeffery
Venue
Applied Clinical Informatics
Publisher
Georg Thieme Verlag KG
Published
2018-10
Volume
09
Issue
04
Pages
914-918
ISSN
1869-0327 (ISSN-L)
DOI
10.1055/s-0038-1676337
PMC
PMC6306276
OpenAlex
W2906623949
Cited by
4
References
18
Citations by year
2024: 3 · 2020: 1
Type
journal article
Language
en
Open access
Locations
  • Applied Clinical Informatics (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
  • Health Sciences › Health Professions › Health Information Management › Medical Coding and Health Information
  • Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
Keywords
electronic health records, physician burnout, administrative burden, prior authorization, documentation burden, EHR implementation, health care efficiency, physician remuneration, quality and safety
MeSH terms
Documentation, Health Expenditures, Health Policy, United States, Centers for Medicare and Medicaid Services, U.S., Guidelines as Topic, Electronic Health Records

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