Physician Alliance Well-Being Case Study: Trinity Health System

Trinity Health

Trinity Health is the nation’s second-largest national Catholic health system with a steadfast mission to be a transforming and healing presence within communities across 22 states. To comply with evaluation and management (E/M) billing requirements, Trinity had revised its history of present illness (HPI) documentation policy in 2012 to exclude the use of ancillary staff notes. This limited the scope of practice for Registered Nurses (RN) and Medical Assistants (MA) in the ambulatory practices. As a result documentation activities, particularly HPI, work shifted to physicians. In 2017, CMS recognized the onerous nature of these rules in the context of electronic health records (EHRs) and increasing population health management. CMS strongly suggested that physician time on medical decisionmaking should be prioritized over documentation. As Trinity embarked on its journey toward teambased primary care, HPI documentation surfaced as an opportunity for improvement. Trinity aimed to redesign the HPI documentation policy to optimize the care team while maintaining compliance with E/M billing regulations.

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