SHM Converge Scientific Abstract ePoster Gallery-Optimizing Risk Adjustment and Quality Through Auto Documentation

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This document describes a hospital initiative to improve clinical documentation using an algorithm-driven “smart phrase” built into the EPIC electronic health record. Accurate documentation is important because it affects severity of illness, risk of mortality, and performance metrics such as Vizient rankings and observed-to-expected mortality. Traditional manual documentation often misses important risk factors in busy clinical settings.<br /><br />To address this, the team implemented a smart phrase in January 2024 across the health system. The tool automatically documents certain diagnoses and associated treatment plans when predefined criteria are met. For example, if a medication is ordered for an electrolyte abnormality, the smart phrase can insert both the diagnosis and the plan. The pilot focused on common CDI-targeted diagnoses and risk-adjustment variables, including electrolyte abnormalities, malnutrition, obesity, and thrombocytopenia.<br /><br />The main measure of success was smart phrase usage, with secondary outcomes including expected mortality and expected length of stay. Since deployment, the tool has been used an average of 53.5% of the time across the institution.<br /><br />Reported results suggest improvement in quality metrics after implementation. Expected mortality increased from 6.86 to 7.27, a 5.99% improvement, and expected length of stay increased from 3.28 to 3.48, a 6.15% improvement. The conclusion is that automating and standardizing documentation can help providers capture patient acuity more accurately, improve hospital performance metrics, and support high-quality care with less effort.

Asset Subtitle

Vijay Duggirala

Meta Tag

Author List Christopher Hritz, Vijay Duggirala

Category Innovations

Concept Clinical Documentation Improvement

Concept Disease Severity

Concept Risk of Mortality

Concept MiCast Smart Phrase

Concept Electronic Health Record

Distinguished Non-Finalist

Presenter Organization Ohio State University

Presenting Author Vijay Duggirala

Track Quality Improvement

Keywords

clinical documentation

EPIC electronic health record

smart phrase

documentation automation

risk adjustment

mortality metrics

length of stay

CDI

hospital performance

patient acuity

Clinical Documentation Improvement

Disease Severity

Risk of Mortality

MiCast Smart Phrase

Electronic Health Record