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. 2023 Apr 12:7:e41223.
doi: 10.2196/41223.

Novel Note Templates to Enhance Signal and Reduce Noise in Medical Documentation: Prospective Improvement Study

Jonah Feldman  1   2 , Adam Goodman  3 , Katherine Hochman  4 , Eesha Chakravartty  1   4 , Jonathan Austrian  1   4 , Eduardo Iturrate  1   4 , Brian Bosworth  4 , Archana Saxena  4 , Marwa Moussa  4 , Dina Chenouda  2 , Frank Volpicelli  5 , Nicole Adler  4 , Joseph Weisstuch  5 , Paul Testa  1
Affiliations

Novel Note Templates to Enhance Signal and Reduce Noise in Medical Documentation: Prospective Improvement Study

Jonah Feldman et al. JMIR Form Res. .

Abstract

Background: The introduction of electronic workflows has allowed for the flow of raw uncontextualized clinical data into medical documentation. As a result, many electronic notes have become replete of "noise" and deplete clinically significant "signals." There is an urgent need to develop and implement innovative approaches in electronic clinical documentation that improve note quality and reduce unnecessary bloating.

Objective: This study aims to describe the development and impact of a novel set of templates designed to change the flow of information in medical documentation.

Methods: This is a multihospital nonrandomized prospective improvement study conducted on the inpatient general internal medicine service across 3 hospital campuses at the New York University Langone Health System. A group of physician leaders representing each campus met biweekly for 6 months. The output of these meetings included (1) a conceptualization of the note bloat problem as a dysfunction in information flow, (2) a set of guiding principles for organizational documentation improvement, (3) the design and build of novel electronic templates that reduced the flow of extraneous information into provider notes by providing link outs to best practice data visualizations, and (4) a documentation improvement curriculum for inpatient medicine providers. Prior to go-live, pragmatic usability testing was performed with the new progress note template, and the overall user experience was measured using the System Usability Scale (SUS). Primary outcome measures after go-live include template utilization rate and note length in characters.

Results: In usability testing among 22 medicine providers, the new progress note template averaged a usability score of 90.6 out of 100 on the SUS. A total of 77% (17/22) of providers strongly agreed that the new template was easy to use, and 64% (14/22) strongly agreed that they would like to use the template frequently. In the 3 months after template implementation, general internal medicine providers wrote 67% (51,431/76,647) of all inpatient notes with the new templates. During this period, the organization saw a 46% (2768/6191), 47% (3505/7819), and 32% (3427/11,226) reduction in note length for general medicine progress notes, consults, and history and physical notes, respectively, when compared to a baseline measurement period prior to interventions.

Conclusions: A bundled intervention that included the deployment of novel templates for inpatient general medicine providers significantly reduced average note length on the clinical service. Templates designed to reduce the flow of extraneous information into provider notes performed well during usability testing, and these templates were rapidly adopted across all hospital campuses. Further research is needed to assess the impact of novel templates on note quality, provider efficiency, and patient outcomes.

Keywords: clinical documentation; clinical informatics; decision support; hospital data; medical informatics.

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Conflict of interest statement

Conflicts of Interest: None declared.

Figures

Figure 1
Figure 1
Data Information Knowledge Wisdom pyramid.
Figure 2
Figure 2
Current state data flow: unprocessed data flows directly from the EHR into provider notes, proposed future state data flow: only data processed into information/knowledge by a clinician or CDS system flows into provider notes. CDS: clinical decision support; EHR: electronic health record.
Figure 3
Figure 3
Timeline and committee structure for an improvement initiative. The green line represents the implementation of GIM standard note templates. GIM: general internal medicine; MCIT: Medical Center Information Technology; NYU: New York University.
Figure 4
Figure 4
Key committee stakeholders. CMO: Chief Medical Officer; MCIT: Medical Center Information Technology.
Figure 5
Figure 5
Guiding principles.
Figure 6
Figure 6
Progress note template for general internal medicine with hyperlinks (arrows). DVT: deep vein thrombosis; I&O: input and output; NYU: New York University; PTA: prior to admission.
Figure 7
Figure 7
Disappearing tip (arrow) for anticoagulation in patients with a planned surgical procedure on full-dose anticoagulation for up to 48 hours prior to surgery.
Figure 8
Figure 8
Disappearing tip for antibiotic plan in patients on intravenous antibiotics and expected time of discharge in the next 24 hours. d/c: discharge; IV: intravenous; PO: by mouth.
Figure 9
Figure 9
Improvements made to the template based on changes recommended from usability testing. DVT Px: deep vein thrombosis prophylaxis; I&O: input and output; NYU: New York University.
Figure 10
Figure 10
Template adoption by provider type and note type. APP: advanced practice provider; H&P: history and physical.
Figure 11
Figure 11
Reduction in note length of consult, H&P, and progress notes following implementation of the new templates. H&P: history and physical.
See this image and copyright information in PMC

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