That well-known but medically complex patient is back in your emergency department (ED). He was seen by your colleague last week and had a big workup, so you pull up her clinical note in the electronic health record (EHR) to review her previous assessment and plan. But, to get to those pearls of information, you’ve got to sift through endless labs and radiology reports, imported meds, and past history. The outpatient workup has continued as well, so it’s not quite clear what data in last week’s ED note is current. Just as you’re making progress, your nurse flags you over to see a different patient.

Medical notes have become plagued with unnecessary information, making them difficult to read, and costing valuable time and attention. “Note bloat” is a distinctly American phenomenon, and occurs across specialties, but longer notes—full of imported results and other data—affect emergency physicians when concise, relevant clinical communication is optimal to make quick decisions on patients with whom we do not have an established relationship. Emergency physicians are often on the receiving end of bloated notes from consultants, or prior discharge summaries—and we also participate in their creation.

Note bloat is multifactorial, but has been aided and abetted by the proliferation of EHRs, which make it easy to import past history, medication lists (often outdated), vital signs, lab results, radiology interpretations, boilerplate phrases, and other elements of a patient’s care into a note via content-importing technology (CIT). This is often done out of the mistaken belief that complete data is necessary or appropriate for billing and coding or to mitigate malpractice risk. However, these superfluous details add little value and make notes harder to parse in the ED.

In January 2023, we will see landmark changes to E/M coding rules (see the article: https://www.acepnow.com/article/2023-documentation-guideline-changes-for-ed-e-mcodes-99281-99285/) from the Centers for Medicare and Medicaid Services (CMS). With these changes, emergency physicians should revisit appropriate documentation–what’s needed for accurately capturing our patient care and medical decision-making and what’s unnecessary and detrimental to clinical communication. A more judicious use of EHR importing capabilities, and use of tools that support linking and prompt summaries should help us make the most of the 2023 coding changes. If physicians do this right, notes will become more useful and readable, without hurting reimbursement or increasing liability.

In recent months members of ACEP’s Health Information Technology Committee, Reimbursement Committee, Coding and Nomenclature Advisory Committee, and Medical-Legal Committee joined forces to author a white paper on this topic, Addressing Note Bloat: Solutions for Effective Clinical Documentation. The authors describe best practices to minimize note bloat and improve clinical communication.

Key Highlights

Recommendations for individual emergency physicians, nurse practitioners, and physician assistants:

A concise, clinically pertinent summary of prior records is sufficient to meet coding requirements for medical decision-making. Importing large volumes of documentation from prior records is not additive and contributes to note bloat.
A concise summary or discussion of results of labs and or radiology tests ordered and/or reviewed by the emergency physician or NP/PA is sufficient to support coding requirements for medical decision-making. Pulling extensive amounts of lab results or complete radiology reports into a note is not additive compared to a concise summary.
While attestation language depends on the type of note, the type of supervision, and federal, state, and institutional rules, in general, a succinct statement indicating the presence and role of the attending physician in the patient’s care is adequate for attestation. A separate documentation of history, exam findings, medical decision-making or other elements of the supervisee’s note is redundant and potentially discrepant, opening the chart to confusion among readers.

Recommendations for ED leadership and hospital-based information technology (IT) departments:

Emergency physicians and NP/PAs should be instructed on the utility, risks, and expectations of CIT. EHR tools facilitating the import of content from results or chart elements can, if used indiscriminately, contribute to note bloat without improving reimbursement or reducing medicolegal risk.
Clinical informaticists and institutional IT departments should play a major role in developing approved, system-wide documentation templates and appropriate CIT, reviewing the quality of templates and CIT already in use, and instructing emergency physicians and NPs/PAs on responsible use. In addition to personalized feedback to emergency clinicians on the quality of their documentation, EHR reports should expand to include CIT usage. Department-endorsed standardized note templates and in-line clinical decision support on appropriate documentation should be employed to guide EM clinicians on structuring their clinical notes.
Note content derived from CIT (such as macros, dotphrases or copy/paste) should be easily identifiable in clinical notes, to support review and validation by the note authors, and let readers understand where CIT was employed.

The sweeping, once-in-a-generation reforms to E/M coding rules planned for January 1, 2023 use medical decision-making (MDM) instead of elements from history of present illness, review of systems, and physical exam to determine the level of service.

Medical decision-making largely depends on the complexity of the patient’s presentation, risk to the patient, and thought processes related to testing and interventions considered or performed. You might be tempted to meet the MDM criteria by importing data into the note, like past medical history, medications, lab, and imaging tests ordered and reviewed. Don’t do it! Those elements are (or should be) visible to clinicians and coders in other areas of the chart. Importing all this data into the note itself will change medical decision-making from a useful distillation of a clinician’s thinking, into a litany of items available elsewhere.

Clinical documentation has evolved considerably over the years, reflecting the influence of technology and various health care stakeholders. Physician notes have evolved from short and succinct handwritten (but often illegible) prose to pages of electronic drivel. Modern ED documentation should concisely describe clinical presentations and communicate medical decision making without sacrificing reimbursement or increasing liability. With the new E/M coding changes upon us, it’s incumbent on ED leadership, hospital IT, and billing and coding staff to work together to make our notes clear and uncluttered.

When that complicated patient returns to your ED starting in January, newer ED notes are a lot easier to read. There’s no more scrolling through countless rows of computer-generated prose about review of systems and exam. Your department has worked with IT and billing and coding to curtail the wholesale import of past history and results, because coders can find that info elsewhere. The MDM section is clear and succinct, only listing pertinent positives and material relevant to clinical communication for today’s ED visit.

Dr. Genes is director of emergency medicine informatics at the Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health.