Background: As surgical and anesthetic practices have advanced, an increasing population of older adults with increased medical complexity are undergoing surgery. A significant portion of these patients may present to the hospital requiring urgent surgical intervention and there is an evolving and expanding role for hospitalists in preoperative risk assessment. However, there remains variable exposure to perioperative medicine in training programs and in clinical practice, leading to a wide range of expertise in preoperative risk assessments and common perioperative complications.
Purpose: In our group, all hospitalists participate in pre-operative risk assessments. Given the importance of preoperative evaluations in complex patients and variable experience with perioperative medicine in our hospitalist group, we sought to develop Epic SmartTools to support clinical decision making for our group members. We also sought to support author efficiency and minimize unnecessary documentation.
Description: We initially created dot phrases with links to risk calculators, both online and using flowsheet calculators, but found that authorship of these notes was burdensome in terms of number of clicks, refreshes, and manual entry of existent patient data. These notes also required significant time from providers to complete and it was difficult to translate risk into narrative assessments and recommendations. With this feedback, we developed Smart Blocks to improve documentation efficiency and ease of use, which allowed us to create a click-through model with built in risk calculators. Data from the patient’s chart was automatically inputted when possible, such as for age, gender, and pre-operative lab values limiting the need to toggle between different epic screens when completing the note. The Smart Block design also allowed for the note to subsequently populate only with final recommendations, streamlining the information and making it easier for consultants and other care team members to easily visualize the pertinent recommendations. We found that the average time spent on writing consult notes decreased by approximately 25%. All hospitalists surveyed preferred using the Smart Block template citing increased efficiency and ease of use as major reasons.
Conclusions: Across the nation, hospitalists have an increasingly important role in providing inpatient preoperative evaluations yet training programs do not uniformly require exposure to perioperative medicine leading to large variability in clinical experience upon graduation. Additionally, preoperative risk assessments can be time-consuming and the burden of clinical documentation in electronic health records (EHRs) may increase physician burnout. Numerous tools within the EHR exist to improve physician efficiency, but it is unclear the optimal way to utilize the EHR to reduce documentation time while simultaneously maintaining high standards to fully optimize complex and increasingly frail preoperative patients. Our experience transitioning from traditional dot phrases to Smart Blocks for pre-operative risk assessments showed that this format improved hospitalist note writing efficiency and streamlined pre-operative evaluations.
