Background: Electronic health record (EHR) systems are used by a majority of US hospitals. EHR use has been associated with increased task complexity, clinical data volume and provider documentation demands. Studies of multiple specialties suggest that a significant amount of provider time is spent on indirect patient care activities including turbulent provider workflows and documentation. Local data suggested direct-care physician providers (1) spent a significant amount of time creating documentation, (2) signed non-initial visit notes late in the work day, (3) relied heavily on copied free text and (4) felt burdened by non-clinical documentation demands. A review of documentation content and workflow was undertaken by hospitalist physician leaders and one physician informatician / builder aimed at improving all of the above metrics. This resulted in creation of a documentation toolkit piloted (with education) by three direct-care hospitalists over an 8-month period.
Purpose: This peer provider-developed, peer provider-built documentation toolkit was designed to incorporate needs from various demands on provider documentation and give providers reliable, supportive content with personalization options. It was also designed to improve provider efficiency and reduce volume of free / copied text by improving integration with EHR data. A relational database captured note creation, content and efficiency data which informed evaluation of the above metrics over time.
Description: The toolkit was developed and enhanced over 4 months (12/2016 and 3/2017). Data from 12 distinct direct-care hospitalists were included. Three direct-care hospitalists were trained with toolkit initiation dates of 4/2017, 4/2017 and 8/2017. Toolkit pilot user data (1,595 notes) was compared to peers (7,662 notes) between 4/2017 and 11/2017. 15,821 total notes were included in the data analysis (initial (1,595), subsequent (11,394) and discharge (2,269) visits). All users created 6,564 notes during the pre-pilot baseline phase (10/2016 and 3/2017) and 9,257 notes (1,595 by educated toolkit users, 7,662 by others) during the pilot phase. Time open, time editing, signature time, % copied text and character count was collected for each note.
Conclusions: A peer provider-developed and built documentation toolkit resulted in decreased time spent documenting (toolkit vs peers vs baseline) both initial (mean 15.4 vs 32.3 vs 28.1 minutes) and subsequent (mean 5.8 vs 9.5 vs 11.0 minutes) visits, earlier subsequent note signature times (mean 11:18 AM vs 1:17 PM vs 1:02 PM) and reduced reliance on copied text (16.7% vs 36.9% vs 46.0%) when educated toolkit users were compared to peers over an 8-month period and 6-months of pre-pilot baseline data. During the 8-month pilot, educated toolkit users spent 148 fewer hours (6.2 hours per provider per month) creating initial and subsequent visit documentation compared to peers. While the creation and measurement of more efficient documentation tools through physician-led initiatives is promising, many questions remain unanswered. Participants were not blinded or randomized and toolkit content was not restricted to educated users. Impact on documentation-driven health system metrics and professional / hospital billing is complex and not yet accounted for. The subjective usability and quality of the toolkit as reported by authors and readers at the point of care was not systematically assessed.