Work with CMS to revise student documentation guidelines
The rules regarding the use of student notes for billing purposes limited the student documentation role to review of systems and/or past family/social history and prohibited teaching physicians from referring to a student’s documentation of other parts of the history, physical exam findings, or decision-making. This team’s task was to explore ways to revise the student documentation guidelines to help relieve unnecessary administrative burdens on preceptors and increase the active learning of students.
Accomplishments:
- Medical student notes do not need to be re-written by the Teaching Physician: Our first big win came in February, 2018, when CMS released a revised transmittal, Pub 100-04 Medicare Claims Processing Manual (updated May 31), that “allows the teaching physician to verify in the medical record any student documentation of components of E/M services, rather than redocumenting the work."
- Multiple students can document the explanation of who can confirm the presence of the Teaching Physician was expanded: On April 26, 2019, CMS released a transmittal, that implemented changes included in the 2019 physician fee schedule. It changed "student" to "students" and goes on to say "The presence of the teaching physician during E/M services may be demonstrated by the notes in the medical records made by physicians, residents, or nurses."
- Advanced Practice Nurses (APNs) and Physician Assistants (PAs) will be able to use student notes: In a proposed rule for the 2020 annual physician fee schedule, APNs (NPs, CSNs, CNMs) and PAs can review and verify their students’ note in the medical record, rather than having to write their own documentation.
In Progress:
- Clarification on physical presence and residents training with students: On August 12, STFM and the other academic family medicine organizations submitted comments in response to a CMS request for information. Among other issues, we requested that CMS clarify both the physical presence issue, and how residents can work with students without redocumenting the note, including within the parameters of the primary care exception. We submitted recommended scenarios again, demonstrating how it should work.
Resources for Implementation of New Guidelines
Integrate interprofessional/interdisciplinary education into ambulatory primary care settings through integrated clinical clerkships
This tactic explores a means to increase the number of learners at a given site without putting more pressure on the clinician’s shoulders. This means transforming education, in conjunction with the practice, away from the 1:1 preceptor/student model.
The team has identified a comprehensive list of opportunities where students could be integrated in useful ways into clinical practice workflows. The list/workflows highlight areas and processes that could accommodate multiple and/or interprofessional students. The workflows will be vetted with preceptors and then translated into implementation tools.
This project is being led by the Physician Assistant Education Association (PAEA).
Status
The next stages of this work have been put on hold until 2020.
Develop standardized onboarding process for students and preceptors & Integrate students into the work of ambulatory primary care settings in useful and authentic ways
This tactic team has developed resources to:
- Ease the administrative burden on community faculty at ambulatory clinical sites by standardizing documentation
- Help preceptors integrate the student more easily into the practice
- Increase student value to the practice
- Aid teaching programs in administering clinical clerkship (rotation) experiences
Status
The team has developed student onboarding resources and processes, including:
The team is developing preceptor onboarding and processes that include:
These resources and processes are being piloted as part of Tactic 4.
Develop educational collaboratives across departments, specialties, professions, and institutions to improve administrative efficiencies
The Tactic 4 team is leading a multi-year pilot called Building Better Clinical Training Experiences: A Learning Collaborative. During the pilot, family medicine departments are participating in one of three projects to implement, evaluate, and disseminate innovative approaches to standardize the onboarding of students and to engage community preceptors.
Family medicine departments were selected for the pilot through a competitive application process. Preference was given to departments collaborating with two or more other specialties/departments/professions. Over the next two years, departments and their collaborators will test the materials and processes being developed as part of Tactic 3, as well as recognition and incentive programs being developed as part of Tactic 5. The teams will participate in online and in-person learning communities to share/learn about intervention approaches; conduct standardized pre/post measurement; and disseminate their findings.
Status
STFM has secured funding for this tactic from the American Board of Family Medicine Foundation, and the Graham Center has agreed to manage evaluation. A call for applications closed on February 22. The selected sites began the pilot project in April 2019.
Promote productivity incentive plans that include teaching & develop a culture of teaching in clinical settings
On December 31, 2018, STFM and ABFM wrapped up a pilot program that offered Performance Improvement continuing certification credit to ABFM diplomates who provided personal instruction, training, and supervision to a medical student or resident and who participated in a teaching improvement activity. Two hundred thirteen (213) diplomates received credit during the 9-month pilot. The program, which has been tweaked slightly based on lessons learned in the pilot, was opened up to additional Sponsors in February 2019. A toolkit for implementation provides instruction and resources.
Competencies for community faculty were developed in collaboration with the STFM Faculty Development Collaborative and have been integrated into a Community Preceptor Self-Assessment Tool that launched on April 2, 2019. The assessment is linked to developmental content on TeachingPhysician.org. This is available to current subscribers to the website, and is being piloted through the Tactic 4 project. A pdf version of the self-assessment is available on the STFM website. Preceptors have completed 28 self-assessments.
A new Master Preceptor Award and a Practice Recognition Award for Teaching Excellence were launched in early June 2019. The awards are being piloted during the Tactic 4 project, and made available online to anyone who wants to use them.
A list of incentives for precepting has been developed at added to TeachingPhysician.org.
Several articles/manuscripts have been published and information has been disseminated through presentations. Communication is ongoing.
