SHM Converge Scientific Abstract ePoster Gallery-Standardizing Documentation of Medical Decision Making in Hospital Medicine: A Quality Improvement Initiative

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This quality improvement initiative at Penn Medicine’s Division of Hospital Medicine evaluated two Epic-based documentation tools designed to standardize medical decision making (MDM) documentation and align with 2023 CMS E/M guidelines. The intervention included a structured progress note and H&P template, plus a modular MDM SmartPhrase that could be inserted into existing notes.<br /><br />The project involved 67 attending physicians and 23 advanced practice providers across four hospitals. After a July 2025 pilot, the division added education and a financial incentive requiring at least 50% tool use. Tool adoption was strong: the tools were used 11,937 times in the first four months, with 99% compliance among APPs and 92% among physicians.<br /><br />The standardized documentation was associated with substantial increases in high-level CPT coding for initial, subsequent, and discharge hospital encounters. High-level coding rose from 11.1% to 38.4% among APPs and from 15.7% to 40.5% among physicians. Tool use was strongly correlated with higher-level coding (r = 0.89, p < 0.001). The initiative generated $38,013 in net revenue during the study period, with a projected annual ROI of $498,830.<br /><br />Usability feedback from 30 survey respondents was generally positive. The structured templates scored better than the SmartPhrase for information quality, interface quality, and overall usability, and clinicians reported willingness to continue using both tools.<br /><br />Overall, the study found that structured EHR documentation tools improved capture of clinical complexity, increased billing accuracy, and enhanced revenue capture while remaining usable and minimally burdensome for providers.

Asset Subtitle

Loukya Kanakamedala

Meta Tag

Author List Amanda Albrecht, Jennifer S. Myers, Joyce Kim, Loukya Kanakamedala, Peter Zhang, Shane Warnock, Zamia C. Diaz

Category Innovations

Concept Clinical Documentation

Concept Medical Decision-Making Documentation

Concept Hospital Medicine

Concept Risk Adjustment

Concept Reimbursement

Distinguished Non-Finalist

Presenter Organization Penn Medicine

Presenting Author Loukya Kanakamedala

Track Quality Improvement

Keywords

Penn Medicine

Hospital Medicine

Epic documentation

MDM SmartPhrase

CMS E/M guidelines

structured progress note

H&P template

high-level CPT coding

billing accuracy

revenue capture

Clinical Documentation

Medical Decision-Making Documentation

Hospital Medicine

Risk Adjustment

Reimbursement