Subscribe to RSS
Decision Support to Improve Critical Care Services Documentation in an Academic Emergency Department
Objectives Critical care services (CCS) documentation affects billing, operations, and research. No studies exist on documentation decision support (DDS) for CCS in the emergency department (ED). We describe the design, implementation, and evaluation of a DDS tool built to improve CCS documentation at an academic ED.
Methods This quality improvement study reports the prospective design, implementation, and evaluation of a novel DDS tool for CCS documentation at an academic ED. CCS-associated ED diagnoses triggered a message to appear within the physician note attestation workflow for any patient seen in the adult ED. The alert raised awareness of CCS-associated diagnoses without recommending specific documentation practices. The message disappeared from the note automatically once signed. We measured current procedural terminology (CPT) codes 99291 or 99292 (representing CCS rendered) for 8 months before and after deployment to identify CCS documentation rates. We performed state-space Bayesian time-series analysis to evaluate the causal effect of our intervention on CCS documentation capture. We used monthly ED volume and monthly admission rates as covariate time-series for model generation.
Results The study included 92,350 ED patients with an observed mean proportion CCS of 3.9% before the intervention and 5.8% afterward. The counterfactual model predicted an average response of 3.9% [95% CI 3.5–4.3%]. The estimated absolute causal effect of the intervention was 2.0% [95% CI 1.5–2.4%] (p = 0.001).
Conclusion A DDS tool measurably increased ED CCS documentation. Attention to user workflows and collaboration with compliance and billing teams avoided alert fatigue and ensures compliance.
Keywordselectronic health records - documentation - critical care - emergency medicine - clinical decision support
Protection of Human and Animal Subjects
The intervention described was performed as part of routine clinical care. The associated retrospective study was reviewed by the Vanderbilt University Medical Center Institutional Review Board and determined not to represent research.
R.W.T. initially designed and implemented the DDS tool, performed the analysis, and led writing of the manuscript. J.C.C. conceived the potential triggers for critical care and curated the list of diagnoses as well as participating in design, implementation, analysis, and writing of the manuscript. B.S.R. led the team from a revenue cycle perspective ensuring that the intervention worked with billing/coding workflows, provided informatics supervision, and contributed substantially to the manuscript. H.S.D. and K.M.J. represented our finance and compliance teams, respectively, and both contributed to the design, implementation, testing, and manuscript authorship. O.E. implemented and tested the tool and created the images used in this manuscript. I.D.J. leads the informatics team at VUMC and supervised the design and implementation of the tool as well as implementation of the SNOMED codes. M.J.W. reviewed and contributed to the manuscript, study design, and statistical review. N.M.M. conceived the project, facilitated mapping of diagnostic concepts to SNOMED codes, participated in design, implementation, and analysis, and contributed substantially to the manuscript.
Received: 18 May 2022
Accepted: 20 September 2022
Accepted Manuscript online:
26 September 2022
Article published online:
16 November 2022
© 2022. Thieme. All rights reserved.
Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany
- 1 Medicare Claims Processing Manual. Chapter 12: Physicians/Nonphysician Practitioners. Rev. 2997, March 25, 2014
- 2 Medicare Critical Care Services Provider Compliance Audit. Clinical Practices of the University of Pennsylvania. Report Number A-03–18–00003; 2020
- 3 Augustine JJ. Where will emergency department volumes go post-pandemic?. ACEP Now 2021;40(08):
- 4 Bennett P, Hardiker NR. The use of computerized clinical decision support systems in emergency care: a substantive review of the literature. J Am Med Inform Assoc 2017; 24 (03) 655-668
- 5 Furmaga J, Courtney DM, Lehmann CU. et al. Improving emergency department documentation with noninterruptive clinical decision support: an open-label, randomized clinical efficacy trial. Acad Emerg Med 2022; 29 (02) 228-230
- 6 Lilly CM, Zuckerman IH, Badawi O, Riker RR. Benchmark data from more than 240,000 adults that reflect the current practice of critical care in the United States. Chest 2011; 140 (05) 1232-1242
- 7 Hobensack M, Levy DR, Cato K. et al. 25 × 5 symposium to reduce documentation burden: report-out and call for action. Appl Clin Inform 2022; 13 (02) 439-446
- 8 Moy AJ, Aaron L, Cato KD. et al. Characterizing multitasking and workflow fragmentation in electronic health records among emergency department clinicians: using time-motion data to understand documentation burden. Appl Clin Inform 2021; 12 (05) 1002-1013
- 9 Frintner MP, Kaelber DC, Kirkendall ES, Lourie EM, Somberg CA, Lehmann CU. The effect of electronic health record burden on pediatricians' work-life balance and career satisfaction. Appl Clin Inform 2021; 12 (03) 697-707
- 10 Lindsay MR, Lytle K. Implementing best practices to redesign workflow and optimize nursing documentation in the electronic health record. Appl Clin Inform 2022; 13 (03) 711-719
- 11 Campbell R. The five “rights” of clinical decision support. J AHIMA 2013; 84 (10) 42-47
- 12 Society for Academic Emergency Medicine. Academic Emergency Medicine's Academy of Administrators in Academic Emergency Medicine (AAAEM) Benchmark Survey. Accessed May 18, 2022 at: https://www.saem.org/about-saem/academies-interest-group-affiliate/aaaem/benchmark-survey2
- 13 Ogrinc G, Davies L, Goodman D, Batalden P, Davidoff F, Stevens D. Squire 2.0 (Standards for Quality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process. Am J Crit Care 2015; 24 (06) 466-473
- 14 American College of Emergency Physicians. Physician Assistants and Nurse Practitioners FAQ. Accessed May 18, 2022 at: https://www.acep.org/administration/reimbursement/reimbursement-faqs/physician-assistants-and-nurse-practitioners–faq/
- 15 American College of Emergency Physicians. Teaching Physician Guidelines FAQ. Accessed May 18, 2022 at: https://www.acep.org/administration/reimbursement/reimbursement-faqs/teaching-physician-guidelines-faq/
- 16 MedData. Descriptors That Highly Suggest Critical Care. Accessed May 18, 2022 at: http://www.meddata.com/wp-content/uploads/2015/11/meddata-critical-care-tool-2015.pdf
- 17 Chong AZ, Kuelbx CL. Disappearing Help for Your Note Templates. Lecture presented at: Epic Expert Group Meeting (XGM). 2019 . Verona, WI
- 18 Brodersen KH, Gallusser F, Koehler J, Remy N, Scott SL. Inferring causal impact using Bayesian structural time-series models. Ann Appl Stat 2015; 9 (01) 247-274