Author: Nikki Blaze (2024)
Advisory Committee: Susan H. Fenton, PhD
PhD thesis: McWilliams School of Biomedical Informatics at UTHealth Houston.
ABSTRACT
Clinical notes of a patient’s visit to a healthcare provider are necessary for patient care, reimbursement, and regulatory compliance with federal and state laws. Over time, non-standardized processes within the EHR have led to the increasing use of copy-paste to complete clinical notes, leading to irrelevant information being captured in the notes. Sinsky et al. (2020) shared that 49% of physicians' time is spent within the EHR, completing their documentation, placing orders, and reviewing the patient's chart. The documentation requirements for billing and coding created tension as clinicians sought ways to reduce the documentation burden. To reduce the documentation burden and give back time to the physicians, we implemented a new clinical note template using integrated functionality within the EHR. We developed new clinical note templates within two ambulatory specialty clinics and three inpatient specialties.
We analyzed the physicians’ documentation practices within the EHR and found three areas to address with a new note template. First, the needs of the writer and reader must be balanced to ensure the writer captures the necessary details of the visit to support the medical decision with the assessment and plan and that the reader has a clinically relevant note communicating the plan for the patient. Second, billing and coding compliance is necessary, but many physicians are unfamiliar with recent E&M coding changes. Third, the use of copy-paste and copy-forward is faster for documenting but leads to irrelevant information captured in the note that does not support the writer's or the reader's needs.
We used the situational awareness model to determine the necessary elements for patient care (including specialty-specific items), billing/coding, and regulatory compliance. We used data from the EHR to determine note length, time in notes, copy/paste usage, and same-day chart closure. Physicians were surveyed before and after the implementation of the new note template. As a result, the new note template produced shorter clinically relevant notes, less copy-paste and copy-forward, less variation in the notes, and good to excellent user satisfaction. Physicians saved 13.6 minutes per ambulatory note and 1.6 minutes per inpatient note using the new note template. Same-day chart closure for ambulatory charts increased by 15%. However, we found the groups with the lowest usage of the new note template may not have been good candidates for the project as they demonstrated efficient documentation practices.
Overall, the project contributed to the informatics discipline by using the information collected in the EHR during the time spent documenting to support the use of a new note template to capture the most relevant information during the patient visit. The net promoter score was 4.4 out of 5 in recommending the new note template. The results also demonstrated a need to develop a process for prioritizing physician specialty groups for candidates needing a new note template.