Decision Support to Improve Critical Care Services Documentation in an Academic Emergency Department

Abstract

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.

Keywords

electronic 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.

Author Contributions

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.

Publication History

Received: 18 May 2022

Accepted: 20 September 2022

Accepted Manuscript online:
26 September 2022

Article published online:
16 November 2022

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