January 6, 2020

Recent History of Physician Documentation

Recent History of Physician Documentation

As quality indicators and CMS metrics become more thorough; doctors are required to spend more time documenting medical care. Specifically, requirements for documentation of resources used and intensity of services will increase the burden on doctors to comply with Medicare regulations, in addition to adjusting with specific payers and other legal requirements. The American Healthcare Association has strongly opposed these rules and urged CMS and ONC to reconsider such rules.

CMS has responded with the Patients over Paper Initiative with the mandate of simplifying documentation regimens which are currently estimated by CMS to require 2 hours of a doctors time for 1 hour of patient care. Our partner physicians have told us that it takes around 10 minutes of concentrated work per patient.

The CMS mandate is to propose and implement new rules for documentation that would enable innovation by doing the following [3]:

(1) Reduce the effort and time required to record information in EHRs for health care providers during care delivery.

(2) Reduce the effort and time required to meet regulatory reporting requirements for clinicians, hospitals, and health care organizations.

(3) Improve the functionality and intuitiveness (ease of use) of EHRs.

According to ONC’s public comments, most clinicians and practices commented on Strategy to reduce burdensome documentation with the Usability of EHRs as the top priority.


[1] Finalized Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2020, CMS, 2019


[2] AHA Says ONC, CMS Need to ‘Rethink’ EHR Documentation Rules


[3] Strategy of Reducing Regulatory and Admin Burdens Relating to Use of Health IT and EHRs.