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.
Status
On February 2, 2018, 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."
The Tactic Team requested from CMS:
- A change to allow the preceptor to use the student documentation even if not in the physical presence of the student
- Clarification that residents can use student notes without redocumenting, including within the primary care exception
- A change to allow nurse practitioner and PA students to be included
- A change to allow nurse practitioner and PA preceptors to use student notes without redocumenting
The team has had several meetings with CMS and HHS an asked the four HRSA Advisory Committees that have jurisdiction over these professions/areas (Council on Graduate Medical Education, Advisory Committee on Training in Primary Care Medicine and Dentistry; the Advisory Committee on Interdisciplinary and Community Based Linkages; and the National Advisory Council on Nurse Education and Practice) to submit letters to the Secretary of HHS and Congress on the issue of student documentation. All agreed. Several concentrated on their areas of jurisdiction and didn’t include all four issues.
On April 26, 2019, CMS released transmittal, that 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."
On May 15, 2019, STFM responded to a request from CMS for information on any ongoing member concerns or confusion about interpretation of the student documentation guidelines. STFM noted that there are various interpretations of "physical presence," and a lack of clarity about resident involvement when a student is also involved in patient care. In some cases, this confusion has hindered implementation of the guidelines. STFM proposed several scenarios that would provide clearer interpretation.
STFM also encouraged CMS to change its policy regarding the inclusion of Advanced Practice Nurses/Physician Assistant students AND preceptors.
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 will be 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 April 2, 2018 the Society of Teachers of Family Medicine and the American Board of Family Medicine kicked off a pilot program that offers Performance Improvement continuing certification credit (previously MOC Part IV) to ABFM diplomates who provide personal instruction, training, and supervision to a medical student or resident and who participate in a teaching improvement activity. The pilot ended on December 3, 2018. The program, which has been tweaked slightly based on lessons learned in the pilot, will be made available to additional Sponsors on February 28, 2019. Family medicine departments, residencies, chapters (or other academic units) that are approved by the ABFM will be able to develop and oversee the completion of performance improvement projects. A toolkit for implementation is now available.
Competencies and incentives for community faculty have been developed in collaboration with the STFM Faculty Development Collaborative, and will be piloted through the Tactic 4 pilot.
Criteria for a Master Preceptor Award and a Practice Recognition Award for Teaching Excellence have been developed. Online submission forms are being created. The awards will be piloted during the Tactic 4 pilot project, and made available online to anyone who wants to use them.
Several articles/manuscripts have been published and information has been disseminated through presentations. There was an update on the preceptor expansion initiative in the February issue of Family Medicine.
