Standardization of Emergency Department Clinical Note Templates: A Retrospective Analysis across an Integrated Health System

Abstract

Background and Objective Clinical documentation is essential for conveying medical decision-making, communication between providers and patients, and capturing quality, billing, and regulatory measures during emergency department (ED) visits. Growing evidence suggests the benefits of note template standardization; however, variations in documentation practices are common. The primary objective of this study is to measure the utilization and coding performance of a standardized ED note template implemented across a nine-hospital health system.

Methods This was a retrospective study before and after the implementation of a standardized ED note template. A multi-disciplinary group consensus was built around standardized note elements, provider note workflows within the electronic health record (EHR), and how to incorporate newly required medical decision-making elements. The primary outcomes measured included the proportion of ED visits using standardized note templates, and the distribution of billing codes in the 6 months before and after implementation.

Results In the preimplementation period, a total of six legacy ED note templates were being used across nine EDs, with the most used template accounting for approximately 36% of ED visits. Marked variations in documentation elements were noted across six legacy templates. After the implementation, 82% of ED visits system-wide used a single standardized note template. Following implementation, we observed a 1% increase in the proportion of ED visits coded as highest acuity and an unchanged proportion coded as second highest acuity.

Conclusion We observed a greater than twofold increase in the use of a standardized ED note template across a nine-hospital health system in anticipation of the new 2023 coding guidelines. The development and utilization of a standardized note template format relied heavily on multi-disciplinary stakeholder engagement to inform design that worked for varied documentation practices within the EHR. After the implementation of a standardized note template, we observed better-than-anticipated coding performance.

 

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Keywords

clinical documentation - electronic health record - note templates

Background and Significance

Clinical documentation completed by health care providers is critical in communicating medical decision-making (MDM), sharing information with patients and other providers, as well as capturing quality, regulatory, and billing data elements for administrative purposes. Variations in clinical documentation structure and content have been highlighted as challenges to the efficient use and safe navigation of electronic health records (EHRs),[1] and overly burdensome design decisions for clinical documentation are associated with increased clinician stress and burnout.[2] [3] The use of individual or personal clinical note templates has been described as “frequent but fragmented,” with individual providers often having a full note template format that is not shared among any of their peers at the same institution.[4] Although personal note templates do have the benefit of flexibility to accommodate individual provider preferences, they may also create wide variation in structure and content, present challenges with maintenance, and potentially include documentation elements that are no longer relevant or against best practice recommendations. Personal note templates also can create maintenance issues related to EHR system upgrades if individuals do not adopt or are unaware of system changes. Growing evidence suggests that standardized documentation results in higher quality notes,[5] [6] [7] including completeness, ease of review,[8] and improved clinician satisfaction.[9] [10] [11] [12]

To date, there is limited literature around the standardization of clinical documentation in emergency departments (EDs), despite such visits having a predictable format and a consistent assignment of evaluation and management (E/M) services for billing and coding. Further, starting in January 2023, the American Medical Association substantially revised the Current Procedural Terminology (CPT) documentation guidelines for E/M services in the ED.[13] [14] Under the new guidelines, several historical documentation elements were no longer required and only advised to be documented as “medically appropriate.” Importantly, the new guidelines placed a much larger emphasis on elements of MDM that would need to be explicitly documented. This change in documentation requirement was described as a “once-in-a-generation restructuring” for all emergency providers who had been using familiar ED coding guidelines dating back to 1992 and led to concerns that the changes would negatively impact reimbursement for a large proportion of ED visits nationally.[14]

Objective

The primary objective of this study is to describe the development, utilization, and coding performance of a system-wide standardized ED note template across a nine-hospital-integrated health system in the southeast United States before and after the 2023 CPT E/M services changes. We hypothesized that the development of standardized and easily accessible ED note templates designed to account for new coding requirements would result in greater than 50% utilization system-wide and with greater standardization realize improved coding/billing performance.

 

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Methods

Setting

This study included nine EDs at a large integrated health system in the southeastern United States. EDs within the health system include a large academic medical center associated with a level one trauma center, and a well-established emergency medicine residency program, as well as community-based EDs including critical access hospitals. ED providers include a mix of private practice, university-based teaching faculty, resident physicians, and health system-employed Advanced Practice Professionals and physicians. All hospitals are on a single instance of Epic EHR,[15] and all ED providers receive structured physician-led EHR training when onboarded. As the health system has grown over several years, different system-level and personal-level note templates have been circulated among the different ED sites. Historically, there has been little restriction on the creation of individual note templates and no formal oversight or review of their use.

 

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Study Design

This was a retrospective study before and after implementing a system-wide note template within the EHR. All study data were collected retrospectively from already existing reporting mechanisms within the EHR related to note template utilization and billing/coding data. No prospective data or survey data were collected.

 

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Note Standardization Process

To develop a standardized template, a multidisciplinary group was convened including medical directors, emergency physicians representing academic and community ED sites, representatives from the two separate professional billing and coding teams (for academic and community ED–based), a senior EHR analyst, a nursing clinical informaticist, as well as a physician informaticist/physician builder. The group systematically reviewed the variations across legacy note templates including differences in note elements, such as five different smart links that were being utilized across the system to display social history, as well as specific differences in methods for providers to capture the complexity of ordered diagnostics (labs, imaging), treatments administered, or other MDM components. This multidisciplinary group determined that components included in legacy notes would be retained in a standardized note if one of the three was true: (1) elements conveyed a clinically relevant piece of clinical data that would be valuable to providers and/or patients reviewing documentation; (2) element met a regulatory and or quality requirement; (3) element was required to capture billing/coding requirements.

To prepare for changes to additional MDM elements required under new coding guidelines, new documentation tools were incorporated and built in a manner that allowed for flexibility in data entry according to provider-preferred workflow. Tools were developed that allowed for the capture of MDM elements including using an optional smart list embedded within the note template, the use of Epic Notewriter MDM smart block (which allows for clicking and navigating a smart form that populates text into notes), and an optional smart list within the ED attending attestation workflow for documenting supplemental elements to the resident note ([Supplementary Appendix 1], available in the online version). After a physician builder built the standardized note template, a version was shared with the multidisciplinary group for revision and approval.

 

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Implementation

A 2-week pilot period was performed across a small group of ED providers in academic and community-based EDs, and ED visits using the new standardized note template during the pilot period were evaluated by billing coding teams according to forthcoming coding changes. During this pilot period minor changes in formatting, such as ordering the most selected options to be near the top, were made to the standardized templates.

Targeted education and physician-led demonstrations of the new templates were shared with medical directors, emergency medicine faculty meetings, and emergency medicine resident didactic conferences. Starting January 1, 2023, a change in the EHR was made that the new standardized ED provider note template be loaded as the default note template for ED providers regardless of which department or facility to which they logged in. To access the standardized note template, ED providers only needed to click “My Note” which launched the standardized template (Epic SmartText ETX record) across all ED sites. ED providers still retained the ability to use a personal template from a blank note or use a voice-to-text dictation platform alone or as an efficiency supplement to note template use.

 

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Outcome Measurement

The inclusion criteria for analysis were ED encounters with a signed ED provider note occurring between July 1, 2022 through June 30, 2023 at one of the nine included EDs. Data related to note template utilization, average note length, ED encounter counts, and ED provider counts were obtained via a combination of the notes reporting workbench report within Epic hyperdrive, as well as querying the Epic Caboodle relational database using Structured Query Language (SQL). Aggregated billing/coding data were collected for providers practicing under the academic and community-based practice model.

 

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Statistical Analysis

Descriptive statistics of note template utilization were reported as counts and proportions, and reported monthly. A secondary analysis of utilization over time was performed by assessing monthly utilization stratified by practice setting. Distribution of billing codes before and after implementation were compared using Chi-squared as well as calculation of adjusted residuals across billing codes. Comparisons of mean note length between periods were performed using a Welch's unequal variances t-test. Statistical significance was set at p <0.05. Data visualization was performed using Microsoft Power BI,[16] and statistical analysis was completed using R.[17]

 

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Results

In the preimplementation period, there were 120,469 ED encounters with 376 ED providers documenting clinical notes ([Table 1]). The proportion of ED encounters using one of six legacy note templates ranged from 0.1 to 36.5% of ED visits. In the postimplementation period, there were 113,639 ED encounters with 363 ED providers. The new system-wide standardized note template was used in 82.0% of all ED encounters and by 84% of ED providers during that time. In the postimplementation period after January 2023, there was a small decrease in the number of attending physicians and resident physicians staffing in EDs across the system, but this did not reach statistical significance on Pearson's Chi-squared testing (χ² = 1.66, p = 0.43). [Fig. 1] describes the monthly utilization of note templates. When stratified by academic versus community-based EDs, there was greater than 75% utilization month over month, and the slightly higher adoption of standardized templates in academic settings stabilized after month 4 ([Fig. 3]).

Table 1 Emergency department (ED) encounters and note template utilization before and after implementation of standardized clinical note template

	Preimplementation Jul 2022–Dec 2022		Postimplementation Jan 2023–Jun 2023
ED encounters with signed ED provider note	120,469		113,639
Unique ED Providers	376		363
Attending physicians	133		123
Resident physicians[a]	91		79
Advanced practice providers[b]	93		104
Structured note template utilization
Legacy template A	43,946	36.5%	0	0
Legacy template B	24,752	20.5%	0	0
Legacy template C	12,070	10.0%	0	0
Legacy template D	102	0.1%	0	0
Legacy template E	10,630	8.8%	0	0
Legacy template F	4,375	3.6%	0	0
2023 template	0	0%	93,138	82.0%

^a Includes emergency medicine residents and off-service residents rotating in ED.

^b Includes physician assistants, nurse practitioners, and medical students.

Fig. 1 Adoption of standardized note templates by month.

Fig. 2 Distribution of the Evaluation and Management (E/M; citation 13) billing codes for academic and community-based practice settings, before and after implementing standardized note templates.

Fig. 3 Monthly utilization of new standardized note template by emergency department practice model.

In the postimplementation period, there was a 1% increase in the proportion of ED visits coded as the highest acuity (E/M Code 99285, 21% in the preperiod vs. 22% in the postimplementation period), as well as a 4% increase in level 2 visits (E/M code 99282, 8% in the preimplementation period, 12% in postimplementation period). The proportion of ED visits coded as level 3 (E/M code 99283) decreased from 40% in the preimplementation period to 35% postperiod. The Pearsons' Chi-squared when comparing the distribution of E/M codes between periods showed a χ² = 1,297.5 (p < 0.01). Adjusted residuals were calculated for each category and the billing codes of 99282, 99283, and 99285 were identified to have an absolute value of adjusted residual greater than 2.[18]

A statistically significant increase in average note length by 464 characters was observed after implementation (prestandardization mean note length 7,481 characters, poststandardization mean note length 7,945 characters, p < 0.001).

 

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Discussion

Across a large integrated health system, we found it is possible to achieve greater than 80% adoption of ED standardized notes by intentional design and template development that would work for all ED providers, regardless of hospital location or type. Equally importantly, we demonstrate a high adoption simply by making a system note template the default template for all ED providers, while still retaining the option for providers to use personal templates if desired. The process of systematically reviewing legacy note templates that had been used across different departments also allowed for a collaborative approach and understanding the historical context for why select departments had certain documentation elements in place, while others did not. This created a collective opportunity to adopt new ideas and/or clarify misunderstandings in documentation elements that may have mistakenly been thought to be necessary. The timing of this note standardization process also coincided with a large shift in billing and coding guidelines for reimbursement, which likely facilitated the creation of a sense of urgency toward standardization. The billing and coding performance after the implementation of standardized notes did not markedly change compared to the preimplementation period; however, this was in the setting of the aforementioned coding changes. In contrast to the anticipated effects of the new coding changes, we observed an increase in the proportion of ED visits coded as E/M code 99285, and an unchanged proportion of ED visits coded as E/M code 99284. Although not rigorously evaluated in our study, it is important to note that changes to billing and coding requirements may have contributed to increased documentation burden such as time spent in notes, ease of reviewing notes, and longer note length to meet billing requirements.

Our findings add to the current literature by describing documentation standardization in the ED setting rather than ambulatory or inpatient setting.[19] [20] Additionally, we demonstrate this standardization across a variety of ED settings, spanning from a high-volume academic ED to critical access rural EDs. More than half of the ED visits in this study were in nonacademic community-based EDs. A key lesson learned from this work was recognizing what has been described by Rosenbloom et al[21] as the tension between structure and flexibility. Specifically in this initiative we intentionally chose to develop flexible but consistent methods for capturing pertinent MDM elements that accommodated provider preference (NoteWriter smart block vs. optional smart lists) as well as accounting for tool availability within different documentation workflows. For example, the use of the NoteWriter smart block functionality to capture the newly required MDM elements while completing the ED attending attestation note was not technically possible. The current documentation workflow to add an ED attestation to a resident note does not allow for the use of the MDM smart block. As such, the decision was made to create optional smart lists that were able to be embedded into ED attending attestation and thus did not require a substantial workflow redesign, while still presenting similar documentation guidance ([Supplementary Appendix 1], available in the online version). Furthermore, after reaching a unified framework of what documentation elements were appropriate or necessary, it is possible to identify opportunities to automatically incorporate pertinent elements that were already being captured discreetly elsewhere[10] but historically required redundant documentation.

Limitations

This work has several important limitations. First, the outcomes measured were limited to the utilization of a standardized template, billing codes, and note length. Inherent in our study design is the assumption that standardization of note templates to align with new coding guidelines would be associated with improved coding performance under the new coding requirements, particularly compared to the lack of standardization in legacy templates. Although no publicly available data are available to compare our findings to EDs that did not undergo similar standardization in anticipation of coding changes, we did not see a marked drop in the proportion of ED visits coded as level 4 (E/M 99284) or level 5 (E/M 99285), as was projected.

Equally importantly, we were not able to assess the effects of this work on clinical workload, clinical documentation quality, or the usability of clinical documentation tools, apart from ED providers contributing greatly to the design and clinical relevance of included documentation elements during the design stage. Further, we were unable to determine how the newly added elements of MDM and implementation of standardized notes contributed to the amount of time spent in notes. This is an important distinction as measurements of time in notes for an ED provider workflow are not available as in other care contexts such as ambulatory or outpatient encounters. Specifically, no Epic Signal data exist for the emergency medicine environment. We did not study how the introduction of a new standardized note template influenced the documentation practices of providers who only use a “personal” smartphrase, and thus it is possible that in the postimplementation period, there remained a subset of ED providers who were using personal-level note templates which were based in part on prior legacy note templates. Additionally, we did not assess for changes in voice-to-text dictation technology usage changes or assess for changes in “copy and paste” practices. Lastly, we did not measure or estimate the anticipated time and information technology resource savings by consolidating from six legacy note templates that historically would need updates and maintenance performed by EHR analysts separately.

 

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Conclusion

In the 6 months following the new 2023 CPT coding changes, we demonstrated that a systematic approach to standardizing note templates in the ED setting is feasible and resulted in greater than 80% ED visits across nine hospitals. A collaborative approach involving representation from clinical and department leaders, billing/coding teams, and information services was critical in driving the development, adoption, and performance of standardized note templates.

 

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Clinical Relevance Statement

Clinical documentation performed by providers caring for patients is increasingly important for capturing medical decision-making and is a vital component of data capture for regulatory, quality, and billing purposes. However, overly burdensome and fragmented documentation leads to challenges around provider efficiency and patient safety, and has been associated with provider dissatisfaction. Efforts to make user-friendly, concise, and intuitive standardized note templates that work for busy emergency department providers are feasible but require intentional time and resource investment.

 

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Multiple Choice Questions

1. Which of the following criteria are reasonable to determine the need for inclusion in standardized clinical note templates (multi-select):

   • Elements that contribute a clinically relevant piece of medical decision-making intended for other providers or patients

   • Elements that have always or historically been included in templates

   • Elements that meet a regulatory or quality measure and are not captured discreetly elsewhere in the electronic health record

   • Elements necessary for accurate billing and coding

   Correct Answer: The correct answers are options a, c, and d.

2. Which of the following is true regarding clinical note template standardization? (single select)

   • All clinical notes must have the same data elements.

   • Clinician adoption will be improved if the documentation tools developed are flexible and can accommodate different documentation preferences.

   • All relevant data in a clinical note must be manually keyed in or dictated by the authoring provider.

   • Longer clinical notes result in higher quality notes

   Correct Answer: The correct answer is option b. Flexibility to accomadate different methods of documentation aids in adoption.

 

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Conflict of Interest

None declared.

Acknowledgment

The authors would like to acknowledge Todd Stroud (Epic ASAP Analyst), Ann-Marie Lee (Clinical Informaticist), and Kim Jones (EHR education specialist) who were instrumental in note template development and the development of EHR education tip sheets for the implementation.

Protection of Human and Animal Subjects

After consultation with our local IRB, this activity did not meet the criteria for human subjects research and did not require IRB review or approval per institutional policy.

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Publication History

Received: 21 December 2023

Accepted: 05 April 2024

Accepted Manuscript online:
08 April 2024

Article published online:
22 May 2024