Background: Variability in documentation has been linked to inefficiencies, increased clinical documentation improvement (CDI) queries, and physician burnout which can negatively impact patient outcomes and hospital revenue. Electronic Medical Record (EMR)-based interventions positively impact patient outcomes, including reducing readmission rates. Moreover, standardized EMR templates may enhance quality with the potential to reduce the burden on CDI initiatives and improve overall hospital efficiency. The primary objective of this quality improvement project was to evaluate the effect of standardized EMR note templates on the number of CDI queries generated for hospital medicine encounters. Secondary objectives included their effect on quality and patient-safety outcomes, documentation time, and billing.
Methods: We conducted a single-center retrospective analysis of standardized note templates, created through an iterative process with faculty experts and leadership, and implemented across all hospital medicine teams. All encounters from 08/2023 to 07/2025 were included. CDI queries, length of stay (LOS), in-hospital mortality, 30-day readmissions, CAUTI/CLABSI rates, discharge disposition, note type, documentation time, relative value units (RVUs), charges, and payments were collected. The data was organized into four operational periods: no template use (08/2024-07/2025), new template with Elixhauser removal (08/2024), Elixhauser reintroduction (01/2025), and the final phase with an automated CDI documentation workflow (06/2025). Descriptive statistics and normality testing were performed along with linear and logistic regression models to evaluate changes in CDI, quality outcomes, billing, and documentation workflow. All analyses were conducted using Stata 17 BE, with statistical significance set at p< 0.05.
Results: There were 19,765 hospital medicine inpatient encounters between August 2023 and July 2025. After the introduction of standardized notes, CDI queries did not change, but they decreased significantly once the new CDI workflow took effect (22 vs 17 average queries per day). Total LOS decreased significantly (8.66 vs 7.06 days), but there were no differences in 30-day readmission rates, in-hospital mortality, CAUTI/CLABSI rates, or discharge disposition across all time periods. The decrease in LOS was not seen in patients cared for by non-hospital medicine teams (n= 17,332). After excluding hospitalists who started after 06/2024, total documentation time increased significantly by approximately 16.5 minutes per day. When analyzed by note type, discharge summaries required significantly more time to complete (12.2 vs 13.9 minutes), while progress notes and history and physical (H&P) notes remained unchanged. Productivity metrics remained stable across periods, except for a significant improvement in RVU billing following the reimplementation of the Elixhauser comorbidity index.
Conclusions: The implementation of standardized EMR note templates may be a feasible and effective strategy to reduce CDI query burden and LOS without negatively affecting quality, patient safety, or productivity. However, provider documentation time increased, which reflect improved documentation quality but could also increase provider burden. While our study supports the notion that EMR-based interventions may reliably improve hospital metrics, more studies are needed to better understand how to utilize them efficiently among providers.
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