Keywords
clinical documentation and communications - encounter level - notes - discharge summary
- electronic health record - confidentiality - clinical decision support - physician
Background and Significance
Background and Significance
Electronic health record (EHR) documentation burden, poor note readability, and “note
bloat” are common problems cited with EHRs and have been associated with increased
provider stress and burnout.[1]
[2]
[3]
[4]
[5] Several factors have contributed to the propagation of lengthy notes that can be
not only difficult to read and write, but also inaccurate.[6]
[7]
[8] These factors include the ease of copy-forward functionality, the ability to automatically
populate data into notes, the use of the note rather than native sections for information
review, and the misinterpretation of billing compliance as requiring that all information
referenced be included in the note itself.[6]
[7]
[9]
[10]
[11] Moving from a SOAP (subjective, objective, assessment, plan) to an APSO (assessment,
plan, subjective, objective) format[10]
[12] and collapsing the individual SOAP sections[13] have been suggested as ways to improve note readability. However, these interventions
do not address the underlying issues: long notes which contain superfluous information,
rendering important clinical data difficult to locate and making the patient story
difficult to follow. Options for clinical decision support (CDS) tools to improve
provider note documentation practices have previously been limited.
Objective
We sought to shift the note paradigm from a repository of copied data to a succinct
summary of the patient story with a focus on medical decision making. As a tertiary
pediatric academic teaching hospital with an obligation to educate trainees on note
writing, we wanted to embed in-line education on note best practices within the note.
Additionally, with an expectation that notes will be shared with patients, we wanted
to create more readable notes while also protecting confidential teen information
from inadvertently being shared with caregivers. We describe our novel solution to
these challenges by creating an unobtrusive CDS tool named “disappearing help text”
and inserting it into inpatient note templates used by the Pediatric Hospital Medicine
(PHM) service.
Methods
The tool was created using existing functionality within the EHR (Epic Systems, Verona,
Wisconsin, United States) and applied to note templates. Text to guide clinicians
is displayed when a note is being written which disappears upon note signature, hence
the name “disappearing help text.” This tool does not interfere with existing functionality
in the note, including keyboard navigation and wildcard selection. The tool provides
guidance on best documentation practices, enhances provider workflow while reducing
need for auto-populated data in the note via hyperlinks to recommended activities,
and enables targeted CDS by displaying specific help text based on patient characteristics.
Providing In-line Guidance for Note Best Practices
We utilized disappearing help text to deliver in-line guidance at the point of care
to note authors for PHM admission, progress, and discharge summary notes. Best practice
guidance included summarizing significant laboratory results rather than auto-populating
entire lists of results into the note via SmartLinks, a tool within Epic that can
automatically populate data from the patient record into a note ([Fig. 1-1]).
Fig. 1 Disappearing help text examples in progress note template. (1) Labs and imaging best
practice documentation; (2) Assessment and plan best practice documentation with problem
list activity hyperlink. (3) Attending attestation activity hyperlinks and billing
reference hyperlink. (c) 2021 Epic Systems Corporation.
Providing In-line Guidance for Billing Compliance
Billing compliance is a frequently cited reason for writing lengthy notes. Disappearing
help text added activity hyperlinks to note templates and instructed providers that
review of the information in the hyperlinks with appropriate linking language would
meet billing requirements without needing to pull the information into the note itself.
Activity hyperlinks are hyperlinks in notes that, when clicked, open a specified activity
page in the EHR. Help text also added a billing guideline reference hyperlink to the
PHM attending attestation template ([Fig. 1-3]).
Enhancing Provider Workflow via Activity Hyperlinks
The activity hyperlinks in help text additionally enhanced provider workflows by promoting
review of patient and encounter level data in appropriate sections of the EHR, rather
than directly in the note. The hyperlinks aimed to reduce note bloat by reducing the
automatic import of non-relevant information into the note for the purposes of review.
They also had secondary aims of (1) promoting structured data entry which could trigger
CDS and enhance reporting, (2) encouraging completion of required documentation, (3)
decreasing EHR documentation burden by reducing clicks, mouse moves, and screen jumps,
(4) allowing other clinicians to easily find patient-level information rather than
searching through notes, and (5) protecting confidential teen information.
Help text and hyperlinks directing providers to EHR activities promoted review and
completion of patient-level items such as past history and medication reconciliation
in shared sections outside of the note ([Figs. 2-2]
[3]). To protect confidential teen information and assist release of information staff,
help text linked to a shared teen history section and guided clinicians to enter confidential
teen history in this section rather than the note unless directly related to the patient's
reason for hospitalization ([Fig. 2-2]).
Fig. 2 Disappearing help text examples in admission note template. (1) In-line guidance
on billing compliance. (2) Rule-based help text for teens with hyperlink to patient-level
shared history activity. (3) Activity hyperlinks to allergies, immunizations, and
home medication reconciliation activities. (4) Rule-based help text for asthma patients
with clinical guideline hyperlink, activity hyperlink, and in-line guidance on best
practice documentation. (c) 2021 Epic Systems Corporation.
Enhancing Attending Review via Activity Hyperlinks
As an academic teaching hospital, another barrier to note bloat reduction is the common
practice of attendings using the note as a record review tool. Help text-based hyperlinks
to EHR activities requiring attending review (shared history, results, and problem
list) were included in the templated attending addendum ([Fig. 1-3]). This facilitated ease of review of the most up-to-date information by the attending
directly in the medical record, while minimizing note bloat.
Rule-Based Help Text for Clinical Decision Support
We designed the help text to interface with patient-based rules, enabling targeted
CDS by displaying help text that varied based on patient characteristics. For example,
to promote note sharing, we provided CDS by displaying a message at the top of inpatient
note templates to elucidate who would have access to the note via the patient portal
based on pediatric patient age and diminished capacity status. Rule-based help text
also provides CDS an appropriate developmental and teen history capture based on age.
We also used patient-based rules to link to clinical guidelines for patients with
specific diagnoses ([Fig. 2-4]).
Data Collection
We evaluated characteristics of first authors admission, progress, and discharge summary
notes before and after help text implementation. The first author is the one who first
signed the note and, after help text implementation, viewed the help text. To evaluate
the impact of disappearing help text on note bloat, we compared pre- and post-intervention
median character count per note and the percent of PHM notes utilizing any laboratory
SmartLink. We analyzed data in the 12 months before and after the addition of help
text to note templates (implemented April 30, 2018 for discharge summaries, September
7, 2018 for progress notes, and June 28, 2019 for admission notes). Due to practice
pattern changes related to the COVID-19 pandemic starting in March 2020, we discontinued
data collection after February 29, 2020. hence, data for admission notes were only
evaluated for 8 months after the addition of help text. As a proxy for note quality,
we evaluated frequency of total coding queries sent to PHM attendings and internal
billing compliance audit performance by PHM attendings during the periods before and
after help text implementation. We also measured incomplete problem list coding queries
to evaluate problem list utilization. Pre- and post-statistical comparisons were made
using STATA 16.1 (College Station, Texas, United States). Chi-square analyses were
performed for percent SmartLink utilization and Wilcoxon Rank Sum test was performed
for median note character count.
Results
In total, 223 distinct providers viewed disappearing help text in PHM notes and consisted
of pediatric and family medicine residents (81%), fellows (4%), nurse practitioners
(4%), and attendings (11%) ([Table 1]). Of all PHM notes evaluated, 73% were first authored by residents or fellows (72%
pre-intervention, 74% post-intervention). After template changes that utilized help
text, the percent of notes utilizing any laboratory SmartLink decreased from 90.2
to 15.3% for admission notes (p <0.001); 92.6 to 17.8% for progress notes (p <0.001); and 14 to 7.2% for discharge summaries (p <0.001) ([Fig. 3]). The median progress note length decreased by 1,251 characters per note (18.7%
reduction, p <0.001), and the median admission note length decreased by 720 characters per note
(6.4% reduction, p <0.001). The median length of discharge summaries did not significantly change ([Fig. 4]). After help text implementation, the average number of all coding queries sent
to PHM attendings decreased from 41.5 to 36.4 queries per month, and the average number
of problem list coding queries sent decreased from 3.5 to 0.4 queries per month ([Table 2]). Pass rates on internal billing compliance audits for PHM attendings were high
at baseline and did not change after help text implementation.
Fig. 3 Percent SmartLink utilization by note type, pre- and post-help text implementation.
For pediatric hospital medicine admission notes (pre: July 2018–June 2019, post: July
2019–Feb 2020), progress notes (pre: Sept 2017–Aug 2018, post: Sept 2018–Aug 2019),
and discharge summaries (pre: May 2017–Apr 2018, post: May 2018–Apr 2019).
Table 1
Note author characteristics. Characteristics of distinct first authors for notes evaluated
in the pre- and post-help text implementation period. The first author is the author
who first signed the note and, after help text implementation, the author who viewed
the disappearing help text
|
Pre-help text
n (%)
|
Post-help text
n (%)
|
|
Provider type
|
|
Resident
|
185 (82%)
|
180 (81%)
|
|
Fellow
|
8 (4%)
|
9 (4%)
|
|
Nurse practitioner
|
9 (4%)
|
9 (4%)
|
|
Attending
|
23 (10%)
|
24 (11%)
|
|
Sex
|
|
Female
|
155 (69%)
|
149 (67%)
|
|
Male
|
70 (31%)
|
73 (33%)
|
|
Specialty
|
|
Pediatrics
|
133 (59%)
|
135 (61%)
|
|
Family medicine
|
66 (29%)
|
61 (27%)
|
|
Pediatric hospital medicine
|
26 (12%)
|
26 (12%)
|
Table 2
Average coding queries per month. By phase of help text implementation and by coding
query type (all types of coding queries and problem list-specific coding queries)
|
Pre-help text
(July 2017–April 2018)
|
Help text added to discharge summary
(May 2018–Aug 2018
|
Help text added to discharge summary and progress note
(Sept 2018–July 2019)
|
Post-help text, all note templates
(July 2019–Feb 2020)
|
|
All coding queries
|
41.5
|
45.5
|
36.4
|
35.9
|
|
Problem list coding queries
|
3.5
|
3.3
|
2.5
|
0.4
|
Fig. 4 Median note character count by note type, pre- and post-help text implementation.
For pediatric hospital medicine admission notes (pre: July 2018–June 2019, post: July
2019–Feb 2020), progress notes (pre: Sept 2017–Aug 2018, post: Sept 2018–Aug 2019),
and discharge summaries (pre: May 2017–Apr 2018, post: May 2018–Apr 2019).
Discussion
Note template changes that utilized disappearing help text significantly reduced the
length of progress and admission notes, a proxy for note bloat reduction. One factor
that likely contributed to note length reduction is the reduced usage of laboratory
SmartLinks, prompted by help text which encouraged authors to only note significant
laboratories rather than using laboratory SmartLinks to automatically import all recent
laboratories. After help text implementation, SmartLink usage was reduced in all three
note types. The decrease in note length did not negatively impact internal billing
compliance audit performance or coding query frequency for PHM attendings, suggesting
that the shorter notes did not degrade note quality.
Notably, we did not see a reduction in character count in discharge summaries even
as the usage of laboratory SmartLinks was reduced by half. This is likely due to a
concomitant change in our Discharge Summary template that added a “Suggested Next
Steps for Primary Care Provider” section,[14] which highlighted significant follow-up needs and would be considered relevant note
information rather than note bloat.
There are several limitations in our analyses. We did not directly evaluate note quality,
and we did not control for the potential impact of concomitant interventions such
as trainee education. Additionally, the notes we evaluated were predominantly trainee-written
notes and limited only to the PHM service, and may not be generalizable to notes written
by attending physicians or notes written by other specialties. Finally, we did not
evaluate the potential contribution of help text to cognitive load.
Within the framework of the five “rights,” quality CDS should be delivered with the
right information to the right person, in the right interventional format, through
the right channel, at the right time in the workflow.[15] Opportunities to provide note-based CDSin EHRs have previously remained limited,
and our disappearing help text tool presents a method for non-interruptive CDS to
be delivered in real time to a provider within the note workflow itself. As with other
forms of CDS, help text should be concise, pertinent, and thoughtfully curated to
minimize contribution to cognitive load and alert fatigue. Directions on replicating
our build have been shared via presentation at the EHR vendor's annual user meeting,
archived tip sheet and presentation on the EHR vendor's user website, and personal
correspondence with the author. Further integration of this tool into EHR platforms
may expand accessibility and utilization of this note-based decision support tool.
Conclusion
We present the novel use of in-line disappearing help text embedded into existing
note templates to improve note readability and accuracy, educate trainees on note
documentation, enhance provider workflow, support billing compliance, and protect
confidential teen information from being inadvertently shared. Our data demonstrate
that help text drove a reduction in the automatic insertion of laboratories into notes
which correlated with a decrease in character count and did not negatively impact
billing compliance or coding queries. Guidance directing clinicians to document confidential
teen information in the shared history section which cannot be pulled into notes may
promote note sharing with both teens and their caregivers while maintaining teen confidentiality.
Further study is warranted into the impact of help text on protecting teen confidentiality,
note quality, documentation accuracy and completeness, trainee education and compliance
with billing regulations. Further study should also explore the value of help text
for providers at differing levels of training and experience, generalizability to
other specialties and contexts, and potential contribution to cognitive load and alert
fatigue.
Clinical Relevance Statement
Clinical Relevance Statement
Disappearing help text is a non-interruptive in-line tool that can provide CDS within
note templates for clinicians at the point of care. This tool can be used to improve
note readability, decrease note bloat, educate trainees on note documentation, protect
confidential teen information from being inadvertently shared, and enhance provider
workflows.
Multiple Choice Questions
Multiple Choice Questions
-
Disappearing help text can be used to address all of the following factors that may
contribute to “note bloat” EXCEPT:
-
Ease of copy-forward functionality.
-
Automatic import of data into notes.
-
The use of the note rather than native sections for information review.
-
Misinterpretation of billing compliance as requiring that all information be included
in the note itself.
Correct Answer: The answer is option a. Disappearing help text encouraged summarizing significant
laboratory and radiology results rather than auto-populating entire lists of results
into the note, directed providers to review information in native sections via embedded
activity hyperlinks rather than in the note, and included guidance on billing and
compliance requirements in the note. Help text did not directly address the ease of
copy-forward functionality.
-
All of the following describe functionality of disappearing help text EXCEPT:
-
Displaying targeted ruled-based clinical decision support in a note based on patient
characteristics.
-
Promoting entry and review of patient and encounter level data outside the note via
activity hyperlinks.
-
Defaulting an APSO note format instead of a SOAP format.
-
Providing in-line guidance on note best practices.
Correct Answer: The answer is option c. Disappearing help text can interface with patient rules to
display targeted clinical decision support in a note based on patient characteristics.
Activity hyperlinks in help text can enhance provider workflow and promote entry and
review of patient and encounter level data outside the note. Help text can provide
in-line guidance on note best practices. While disappearing help text could recommend
a particular note format such as APSO, it does not cause this format to be defaulted
in the note.
