Improving Provider Documentation Using a Pediatric Automated Documentation Assistance Tool.

Area of Science:

• Health Informatics
• Pediatric Hospital Medicine
• Clinical Documentation Improvement

Background:

• Electronic health record (EHR) tools for clinical documentation integrity (CDI) are not well-established in pediatric care.
• Improving documentation accuracy and efficiency is critical for pediatric inpatient providers.

Purpose of the Study:

• To adapt and implement a real-time, automated documentation assistance tool (AutoDx) for pediatric use.
• To decrease clinical documentation integrity (CDI) coding queries and improve the perceived ease of practice for pediatric inpatient providers.

Main Methods:

• Adapted and implemented the AutoDx tool with pediatric-specific logic rules at an urban academic pediatric hospital.
• Assessed the primary outcome of CDI queries per 1,000 discharges for targeted diagnoses over a 5-month implementation period.
• Evaluated secondary outcomes including provider-surveyed ease of practice and tool uptake.

Main Results:

• The aggregate rate of targeted CDI queries decreased by 58% postimplementation (80.7 to 33.9 per 1,000 discharges; p < 0.001).
• Interrupted time series analysis showed an immediate 45.5% reduction in coding queries (p = 0.028), with no change in nontargeted diagnoses.
• Tool adoption increased steadily, and 46% of providers agreed the tool improved the ease of providing quality care.

Conclusions:

• Real-time automated documentation support tools can significantly reduce CDI coding queries in pediatric inpatient settings.
• Despite a "task substitution" effect, the AutoDx tool enhanced perceived ease of practice, demonstrating the value of targeted EHR interventions in pediatrics.