News: Use of SmartTools and copy/paste increased ‘note bloat’ by 8%, study finds

CDI Strategies - Volume 17, Issue 28

A new study conducted by Epic Research found that between 2020 and 2023, clinical notes had increased from 4,628 to 5,002 (an 8% increase). During that same period, however, providers had reduced the average time spent on each note from 5.4 to 4.8 minutes (an 11.1% decrease), Healthcare IT News reported.

Epic Research reviewed 1.7 billion clinical notes from 166,318 outpatient providers written between May 2020 and April 2023. The study was issued to assess the effect of the 2021 changes to the Centers for Medicare and Medicaid Services’ (CMS) evaluation and management CPT billing codes.

The report observed that a key factor in determining the length of clinical notes was the use of SmartTools and copy/paste functionality:

We found that organizations that reduced their use of SmartTools—documentation tools that make it easy to add additional content to notes from other places in the patient’s chart—and copy/paste functions also reduced their average note length. Conversely, organizations that increased note length saw stable use of SmartTools and increased use of copy/paste functions.

The report noted that the 10% of providers who decreased their note length represented a “wide variety of specialties” including primary care, internal medicine, surgical specialties, dermatology, cardiology, and psychiatry. According to the authors, this suggests that a “reduction in note length” is achievable in “nearly any specialty.”

Editor’s note: To read the Healthcare IT News article, click here. To read the Epic Research report, click here.

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