Strategies To Streamline EHR Documentation For Telehealth Visits

EHR Documentation

Electronic health records (EHRs) allow physicians to manage clinical information in an effective way and share patient data with other health providers. Outsourcing medical transcription helps them ensure timely and accurate EHR documentation. Remote medical consultations became an effective tool for patient interactions and care during the pandemic. Recent reports say that the demand for video medical visits is likely to continue to increase. As Seema Verma, Administrator of The Centers for Medicare and Medicaid Services (CMS) stated, “the genie is out of the bottle on this one” and there’s no going back on telehealth.

Telehealth Visits are Burdensome for Physicians, say Studies

While virtual consults are a convenient, cost-effective option for patients, recent studies found that physicians are working after-hours to complete EHR-based clinical and administrative work, including documentation, leading to burnout. The authors of a study published in Perspectives Health Information Management in January 2022 reported that “current practices in telehealth documentation are progressing toward but not yet completely meeting best practice goals”. The study noted that the rapid adaptation of telehealth within the last 18 months and the uncertainties in related documentation standards have left many without clear guidelines.

MobiHealthNews reported on another recent study that was published in JMIR in July found that time spent on work-related tasks outside clinical hours, often referred to as “work outside work” (WOW), increased “significantly” for those physicians who spent a larger proportion of their time providing care via telemedicine. The study, which covered 2,129 physicians, was conducted at New York University Langone Health. “Taking physicians’ clinical load into account, physicians who devoted a higher proportion of their clinical time to telemedicine throughout various stages of the pandemic engaged in higher levels of EHR-based after-hours work compared to those who used telemedicine less intensively,” the authors concluded. “This suggests that telemedicine, as currently delivered, may be less efficient than in-person-based care and may increase the after-hours work burden of physicians.”

The good news is that there are various options to streamline and optimize EHR documentation for telehealth visits.

Best Practices to Optimize Telehealth Documentation

  • EHR telehealth integration: Integrating a telehealth platform into the EHR and patient portal can ease clinician burden and ease documentation. With standard EHR design, physicians need to click through multiple screens and form fields, diverting attention from the patient. Though modern cloud-based telehealth platforms are focused on the provider experience, fatigue and digital overload still persist. It has been found that the solution lies in integrating telehealth and EHR technology.

    With an EHR-integrated solution, physicians can avoid making multiple clicks to navigate between documentation and video screens. When all the data is integrated on one platform, clinicians can view the patient’s journey map on a “single pane.” This decreases cognitive workflow and reduces clinician burden, explains David West, MD, medical director of health informatics at Nemours Children’s Health (

    Other benefits of integrating telehealth and EHR technology according a report include:

    • Creates simplified and seamless virtual care workflows that offer the same validity as face-to-face patient/provider interactions
    • Enhances the patient’s telehealth experience – they can understand their diagnoses better, and view their history when the session is complete
    • Enables physicians to verify patient eligibility, which is important for claim submission and reimbursement for services
    • Avoids duplicate entries (in the EHR and telehealth system), reduces risk of errors and improves clinical efficiency
    • Streamlines patient care in one single clinical workflow, making patient check-in and interactions easier for staff

    So, an integrated solution provides many benefits for both providers and patients.

  • Setting up a second screen: While EHR telehealth integration brings the patient journey visible on a single pane, it is not available everywhere. Adding a second screen via a laptop or tablet is a practical option in this situation. The American Academy of Family Physicians (AAFP) recommends using a second screen to make documentation easier during a telehealth consultation. The physician can use the primary screen for the telehealth camera and the electronic health record (EHR), and the second screen for viewing the patient in real time. This arrangement makes it easier for the physician to enter data in the EHR while looking at and talking to the patient.
  • Using voice recognition technology: Speech recognition technology (SRT) is used by many providers to manage EHR documentation. With surging patient volume during the pandemic, the use of this EHR scribe solution surged, improving workflow efficiency.

Other best practices that the Perspect Health Inf Manag. study recommends to streamline telehealth documentation include:

  • Supporting telehealth billing requirements and training medical students on documentation guidelines for telehealth services
  • Calculating visit time correctly
  • Modifying note templates in the electronic health record to meet telehealth documentation requirements
  • Developing procedures and forms to make documentation as streamlined as possible
  • Prioritizing continuous monitoring of the guidelines on telehealth documentation from national and discipline-specific organizations
  • Fostering compliance by updating policies and procedures to include telehealth chart audits

Outsource Medical Transcription

Outsourced medical transcription services can improve the efficiency of all the above-mentioned strategies and reduce clinician stress. Experienced service providers deliver EHR-integrated transcription solutions, including review of SRT-generated transcripts.

Telehealth is here to stay and every practice needs to adopt the right strategies to streamline the documentation of remote medical visits. With the shift to value-based care, the importance of a team-based approach has also increased. Seamless data sharing can promote proper care coordination, care quality and outcomes, not only among nurses, care managers, and other clinical staff in a facility but also with specialists across geographies. Outsourcing medical transcription can ensure quality data for sharing across various setting and the health care continuum.

Julie Clements

About Julie Clements

Joined the MOS team in March of 2008. Julie Clements has background in the healthcare staffing arena; as well as 6 years as Director of Sales and Marketing at a 4 star resort. Julie was instrumental in the creation of the medical record review division (and new web site); and has especially grown this division along with data conversion of all kinds.