Department of Pediatrics, University of California San Diego/Rady Children's Hospital, San Diego, California, United States.
Appl Clin Inform. 2022 Oct;13(5):1033-1039. doi: 10.1055/a-1934-8323. Epub 2022 Aug 31.
The authors describe a novel solution to the challenges of lengthy notes and poor note readability by creating an unobtrusive clinical decision support tool named "disappearing help text."
We designed this tool in Pediatric Hospital Medicine (PHM) note templates to provide in-line decision support on best documentation practices, note bloat reduction, billing compliance, and provider workflow enhancement.
After template changes that utilized disappearing help text, we reduced the percent of notes utilizing any laboratory SmartLink from 90.2 to 15.3% for admission notes ( <0.001), 92.6 to 17.8% for progress notes ( <0.001), and 14 to 7.2% for discharge summaries ( <0.001). In admission and progress notes, this correlated with a significant reduction in the median note length as a proxy of note bloat reduction, with a 18.7% character count reduction in progress notes ( <0.001) and a 6.4% reduction in admission notes ( <0.001). PHM coding queries decreased from an average of 42 per month to 36 per month, and there was no change in PHM attending billing compliance audit performance.
Note template changes that utilized disappearing help text significantly reduced the length of both progress and admission notes, a proxy for note bloat reduction, without negatively impacting coding query frequency or internal billing audit performance. One factor that likely contributed to this reduction in note length is the reduced usage of laboratory SmartLinks prompted by disappearing help text.
We present the use of in-line disappearing help text embedded into note templates as a clinical decision support tool to improve note readability, educate trainees on note documentation, and protect confidential teen information. Help text implementation correlated with a reduction in the automatic insertion of laboratories into notes and a decrease in note character count.
作者通过创建一个名为“消失的帮助文本”的不显眼的临床决策支持工具，来解决冗长的笔记和较差的笔记可读性问题。
我们在儿科医院医学（PHM）的笔记模板中设计了这个工具，为最佳文档记录实践、减少笔记膨胀、计费合规性和增强提供者工作流程提供在线决策支持。
在利用消失的帮助文本更改模板后，我们将使用任何实验室 SmartLink 的笔记百分比从入院笔记的 90.2%降至 15.3%（<0.001），从进度笔记的 92.6%降至 17.8%（<0.001），从出院总结的 14%降至 7.2%（<0.001）。在入院和进度笔记中，这与减少笔记膨胀的代理即中位数笔记长度的显著减少相关，进度笔记的字符数减少了 18.7%（<0.001），入院笔记减少了 6.4%（<0.001）。PHM 编码查询从平均每月 42 次减少到每月 36 次，而 PHM 主治医生计费合规性审计绩效没有变化。
利用消失的帮助文本更改笔记模板显著减少了进度和入院笔记的长度，这是减少笔记膨胀的代理，而不会影响编码查询的频率或内部计费审计的性能。导致笔记长度减少的一个因素可能是消失的帮助文本提示实验室 SmartLink 的使用减少。
我们提出将嵌入式在线消失的帮助文本用于笔记模板作为临床决策支持工具，以提高笔记可读性、教育受训者记录笔记，并保护青少年的机密信息。帮助文本的实施与实验室自动插入笔记以及减少笔记字符数相关。
