Until recently, guidance from the Centers for Medicare and Medicaid Services (CMS) for teaching physicians about medical student documentation in the medical record1 had inadvertently hampered medical education and increased the administrative and regulatory burden on the teaching physician. CMS guidelines limited the medical student documentation role to only recording a Review of Systems and/or the Past Medical, Family and Social History. The teaching physician had been prohibited from referring to a student’s documentation of the other parts of the history, physical exam findings, or medical decision making. Although these guidelines did not prohibit students from writing in the medical record, many health care systems prevented or severely restricted student access to documentation in the electronic health record (EHR) based on their interpretation of the guidelines. As a consequence, many medical student notes never got reviewed, students did not learn documentation skills from preceptor feedback, and teaching physicians had to spend their time redocumenting clinical encounters rather than teaching the students who were working alongside them in the clinical setting.
On February 2, 2018, CMS released a revised transmittal, Pub 100-04 Medicare Claims Processing Manual, which “allows the teaching physician to verify in the medical record any student documentation of components of E/M [Evaluation and Management] services, rather than re-documenting the work.”2 This is a significant change in response to persistent thoughtful advocacy from the medical education community, and we are grateful to the CMS leadership for supporting medical training in this manner. If health systems recognize and respond to this change, medical education will be advanced and students will be better prepared for residency. This change both enables more authentic clinical experiences for students and helps to address the preceptor shortage by decreasing the clinical documentation burden that preceptors face when working with students. We write to call attention to this change and to encourage health systems to optimize this opportunity. Health systems, working with their compliance teams, must evolve their internal policies to relieve their teaching faculty of documentation burdens and to maximize the student learning opportunities that this transformative change allows.
It is important to recognize that this policy change, while eliminating unnecessary duplication of effort, does not threaten patient safety or increase risk of fraud. There has never been evidence that the increased burden of educational documentation has been associated with improved quality of care. As before, physicians can still only bill for the work that they personally perform: It would be both fraudulent and medically negligent for physicians to submit charges for work that they do not personally perform, such as clinical care only delivered by a student. Under the new rule, teaching physicians must continue to actively supervise and take responsibility for any work that a medical student might perform as a member of their clinical team. This policy change does not affect the clinical supervision of students but, rather, simply allows medical students to document a clinical encounter in the EHR and to have that documentation support the billing of their supervising physicians.
Medical students must learn to document while being closely supervised because they are expected to document independently in the EHR upon graduation.3 As medical educators know, the Association of American Medical Colleges recommends that all medical school graduates be entrusted to complete 13 Core Entrustable Professional Activities for Entering Residency (Core EPAs) by day 1 of residency.4 Two Core EPAs in particular emphasize the importance of clinical documentation skills: EPA4 addresses student competency “to enter and discuss orders and prescriptions,” and EPA5 requires that the student be competent to “document a clinical encounter in the patient record.”4 To achieve competence, of course, requires practice and then repeated application. It is difficult, if not impossible, for medical students to achieve EPA4 and EPA5 if they are not allowed meaningful and frequent access to documentation in the EHR. Until now, because of the CMS guidelines, many medical students were entering residency with inadequate training and insufficient experience in documenting effectively. We anticipate that this CMS policy change will allow students to participate more fully as team members in the provision of clinical care and thereby be more facile with documentation before they commence residency.
In addition, we have a preceptor crisis in medical education.5 The number of students seeking training at community sites has rapidly increased at a time when it is ever more difficult to recruit community physicians as teaching faculty.6 Community physicians face pressure to see more patients and consequently spend additional hours per day completing documentation. So, why would they, on top of that, volunteer to teach a student who is not allowed to play a role in documentation? This change in CMS policy will support clerkship directors in their efforts to recruit and retain community preceptors and reward rather than punish the act of precepting as students actively contribute to the clinical care of patients.
The revised guideline, which had an implementation date of March 5, 2018, states:
Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work. (Changes italicized.)
As we write, medical educators and compliance officers across the country are revising their student documentation policies to reflect this update. Typically, a medical student will interview and assess a patient first and then orally present his or her findings and impressions to the teaching physician. A simple, effective, and compliant strategy that allows the teaching physician to verify the presented history with the patient (as they must do per this guideline) is to Precept in the Patient’s Presence (PIPP)7 in the exam room or on family-centered bedside rounds.8 Thereafter, the teaching physician can examine the patient and complete medical decision making together with the medical student, patient, and team members, and the student can document the encounter note, which the teaching physician will review, attest, and submit for billing.
This important change in CMS policy comes after extensive advocacy work by many individuals and groups of medical educators. Specifically, an interprofessional, interdisciplinary team from the Precepting Expansion Initiative led by the Society of Teachers of Family Medicine met with CMS in December 2017, providing arguments in favor of the change and proposing revised transmittal language. The CMS response to this work is appreciated, and is in line with efforts throughout health care systems to improve quality and eliminate waste.
Now it remains for our medical schools, residency programs, and health care systems to capitalize on this opportunity and continue to press for rational documentation requirements in both undergraduate and postgraduate education that are minimally burdensome and whose sole purpose is to promote the health of the public and improve quality of care.
With gratitude to the many advocates, deans, medical educators, compliance officers, preceptors, students, and patients who lobbied for this change, and to the leadership at the Centers for Medicare and Medicaid Services who responded to the need for reform.
3. Englander R, Flynn T, Call S, et al. Toward defining the foundation of the MD degree: Core entrustable professional activities for entering residency. Acad Med. 2016;91:1352–1358.
5. Christner JG, Dallaghan GB, Briscoe G, et al. The community preceptor crisis: Recruiting and retaining community-based faculty to teach medical students—A shared perspective from the Alliance for Clinical Education. Teach Learn Med. 2016;28:329–336.
6. Beck Dallaghan GL, Alerte AM, Ryan MS, et al. Recruiting and retaining community-based preceptors: A multicenter qualitative action study of pediatric preceptors. Acad Med. 2017;92:1168–1174.
7. Power DV, Rosenbaum ME, Hanson L, et al. Precepting medical students in the patient’s presence: An educational randomized trial in family medicine clinic. Fam Med. 2017;49:97–105.
8. Cox ED, Schumacher JB, Young HN, Evans MD, Moreno MA, Sigrest TD. Medical student outcomes after family-centered bedside rounds. Acad Pediatr. 2011;11:403–408.