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Improving IV Insulin Administration in a Community Hospital

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New Coding Guidelines Reduce Emergency Department Note Bloat But More Work Is Needed.

Kyle Marshall¹, Ron Strony², Ben Hohmuth³

¹Geisinger, Steele Institute for Health Innovation, Danville, PA; Geisinger, Department of Emergency Medicine, Danville, PA.

Annals of Emergency Medicine

|September 1, 2023

Summary

New guidelines reduced emergency department (ED) note length by 872 words, combating "note bloat." However, clinician documentation time remained unchanged, indicating potential for further optimization in healthcare documentation practices.

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Area of Science:

Health Informatics
Clinical Documentation Improvement
Healthcare Administration

Background:

Clinician notes have increased in length, a phenomenon termed "note bloat."
This increase impacts efficiency and potentially patient care.
Addressing note bloat is crucial for optimizing healthcare workflows.

Purpose of the Study:

To analyze the effect of new coding guidelines and documentation best practices on emergency department (ED) note length.
To assess the impact of these changes on clinician documentation time.

Main Methods:

Retrospective evaluation of 1,679,762 ED provider notes from a large, multisite healthcare organization (February 2018 - June 2023).
Implementation of standardized note template changes in January 2023, aligning with American Medical Association and Centers for Medicare & Medicaid Services coding guidelines.
Primary outcome measures: ED provider note length and clinician documentation time.

Main Results:

Average ED provider note length decreased by 872 words six months post-intervention.
No significant change was observed in the amount of time clinicians spent documenting.

Conclusions:

Successfully reduced ED provider note length by 872 words through adoption of new guidelines and practices.
Documentation time for clinicians did not significantly change, suggesting further opportunities to reduce burden.
This study offers early insights into mitigating note bloat in the ED setting.