The One Note System: Implementation and Initial Perceptions of Student Documentation in the Electronic Health Records Under the New Centers for Medicare and Medicaid Services Guidelines
| Autor: | Adam M. Garber, Rebecca E. Miller, Evan M Dombrosky, Steven Bishop, Komal Safdar, Marieka Helou, Claire Kimberly |
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| Rok vydání: | 2020 |
| Předmět: |
media_common.quotation_subject
030204 cardiovascular system & hematology Burnout 03 medical and health sciences 0302 clinical medicine Documentation Internal Medicine Medicine Quality (business) cms guidelines Implementation media_common Service (business) Medical education business.industry General Engineering electronic health record Quality Improvement student documentation patients over paperwork Workflow Medical Education Work (electrical) note bloat business Medicaid 030217 neurology & neurosurgery |
| Zdroj: | Cureus |
| ISSN: | 2168-8184 |
| DOI: | 10.7759/cureus.9702 |
| Popis: | Introduction Medical students have been documenting notes in the electronic health records (EHR) for many years but often wrote separate notes from housestaff and faculty because licensed providers (LPs) could not bill the Centers for Medicare and Medicaid Services (CMS) for Evaluation and Management (E/M) services. However, in 2018, CMS updated its policy to allow LPs to simply verify any component of an E/M service under appropriate supervision, allowing LPs to bill a full medical student note. Methods At Virginia Commonwealth University Health Systems (VCUHS), a task force was formed to develop and pilot the One Note System (ONS), a system that incorporates the new CMS guidelines for certain note types. In June 2019, or 10 months after implementation of the ONS, the authors developed and distributed a survey that explored perceptions regarding the ONS among medical students, housestaff (residents and fellows), and faculty. Results The results showed that most participants were aware of the ONS and preferred email as the form of training. Overall, the ONS had a positive impact on faculty and housestaff workflow, improved self-reported faculty wellbeing, and increased meaning in student work. Only a minority reported barriers to implementing the ONS. Conclusions The One Note System was successfully implemented at VCUHS and positively received. Other outcomes to measure include impact of the ONS on student and trainee education, compliance and billing, quality and quantity of documentation, and faculty and housestaff burnout rates. |
| Databáze: | OpenAIRE |
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