P3B412: Milestone and Metrics, Creating a Simple Quantitative Developmental Narrative

Background: While the implementation of the electronic health record (EHR) has provided greater efficiency and supported clinical decision making, it has also increased the pediatrician’s documentation workload with additional billing, regulatory and reporting requirements. Increased documentation tasks during the clinical encounter can disrupt the patient-pediatrician interaction and extend after-hours documentation time (often referred to as pajama time). This documentation burden has been associated with negative impacts to patient safety, declining documentation quality, worsening provider burnout, and, to save time by copying text, exacerbating “note bloat”. Adding to this burden, our State’s Medicaid program has required additional documentation for quality reporting metrics in our Federally Qualified Health Centers’ (FQHC) pediatric clinics. Our objective was to create new documentation capabilities and utilize updated note templates for well-child visits (WCV) to ease the documentation burden and better capture quality metrics.

Methods: After thorough review of state health insurance documentation requirements and pediatrician documentation workflow at our FQHC clinics, we compared existing documentation templates and found quality reporting gaps. Within our academic center’s EHR (Epic, Verona, WI), our team created personalized NoteWriter forms (Figure 1), which allows for point-and-click documentation and data capture for reporting, with underlying age-based logic, to (1) quickly track the child’s developmental milestones according to the age of the WCV, based on new guidelines developed by the Centers for Disease Control and Prevention (CDC) and American Academy of Pediatrics (AAP), with one-click capability to record normal development for age, and (2) assess medical and psychosocial risk factors according to Bright Futures and AAP, based on age of the WCV, with one-click capability to record negative findings. Additionally, we created new WCV note templates with “disappearing” links to access documentation tools without requiring the user to exit the note (Figure 2). Lastly, utilizing age-based logic, we created an age-specific WCV order set that contained default choosing of age-specific note template; patient instructions; level-of-service code; diagnoses codes; and nursing orders utilized in our WCVs to further streamline physician tasks.

Results: Data and survey collection was underway at the time of submission. Preliminary data shows a decrease in charting time between 23% to 47% among pediatricians with varying years of experience. Preliminary user feedback includes: “The order set is so fast; helps me put in the diagnosis codes and orders, I would use it right away.”; “Forms will take some getting used to but it's easy to use, results show in the note.”

Conclusion: By integrating existing EHR functionality within our established documentation workflow, our multi-modal intervention decreased physician documentation time. Preliminary feedback indicates a high likelihood of acceptance, allowing for the capture of developmental milestones and quantitation of quality metrics while decreasing documentation time, which may lead to improved patient-pediatrician interaction and decreased physician burnout.