Assessing Usage Patterns of Electronic Clinical Documentation Templates
This is a review of a paper submitted by David K. Vawdrey 
Do large academic medical centers need large amounts of clinical documentation templates to conduct their clinical business?
The purpose of this study describes the design of business intelligence tool for tracking usage of electronic documentation templates within a vendor-based electronic medical record (EMR) system.  At the New York-Presbyterian Hospital (NYP) institution, comprising of two large academic medical centers, a documentation management data mart and a custom and a Web-accessible business intelligence application were developed to track the availability and usage of electronic documentation templates. By February 2008, approximately 65,000 electronic notes were authored per week on the two campuses. One site had 934 available templates, with 313 templates being used to author at least one note. The other site had 765 templates, of which 480 templates were used. The most commonly used template at both campuses was a free text note called “Miscellaneous Nursing Note,” which accounted for 33.3% of total documents generated at one campus and 15.2% at the other. 
Both the Columbia and Weill Cornell campuses of NYP recently completed the installation of a vendor based electronic medical record (Eclipsys Sunrise Clinical Manager 4.5 XA, Eclipsys Corp., Atlanta, GA). The Eclipsys system was used to provide a computerized provider order entry capability and was the primary source for clinical documentation entered by nursing and ancillary staff. In 2007, hospital leadership encouraged physicians, physician assistants, and nurse practitioners to adopt electronic documentation within Eclipsys on a voluntary basis. To support the migration to electronic documentation in Eclipsys, hundreds of free-text and structured documentation templates were created to supplement the pre-defined templates supplied by the vendor. Over time, the growing number of templates became difficult to manage, more so because templates used at the two hospital campuses were not always identical. Tracking the usage of templates was rarely performed because it required time- and labor-intensive database queries and manual aggregation of statistics. 
Care providers consisting of physicians, nurses and ancillary personal entered structured and tree-text clinical notes using the Eclipsys “Document Entry Worksheet”.  This application allowed a care giver provider to select a documentation template using either a “tree widget” or picking the desired template from a dynamic filter list.  A documentation management data mart was created within the clinical data warehouse and was updated weekly with template maintenance information and usage statistics. A Web-accessible tool was developed by a third party to track the availability and usage of electronic documentation templates.
By February 2008, NYP/Columbia University Medical Center campus had 934 available templates, with 313 templates being used to author at least one note. The NYP/Weill Cornell Medical Center campus had 765 templates, of which 480 templates were used. The most commonly used template at both campuses was a free text note called “Miscellaneous Nursing Note,” which accounted for 33.3% of total documents generated at one campus and 15.2% at the other. The largest volume of notes for both campuses was generated with nursing documentation templates.
The 10 most common templates at NYP/Columbia were used to create 61.7% of total documents, while the top 10 templates at NYP/Weill Cornell accounted for 41.1% of notes authored there. Only a fraction of the available templates were used by care providers writing clinical notes (30% at one campus, 60% at the other).1 Only 5 of the 10 most common templates were used or shared between both campuses.
Before the availability of the tracking application, templates at this institution were seldom retired—typically only when a template was replaced by an updated version. Having access to the usage frequency for each template allows system administrators to judiciously prune unused templates, resulting in a more organized and parsimonious collection of templates available for clinical documentation. A small number of templates were responsible for most of the electronic notes that were written. At one campus, “Miscellaneous Nursing Notes” constituted one-third of the total. The author reported another reference by Payne et al. who reported a similar finding, where 32 out of 244 available templates (13.1%) accounted for 75% of all notes authored.
While both medical centers process large amounts of clinical documentation templates to generate Electronic Medical Records, not all templates are used at one time. Clinical providers create new templates to satisfy their clinical work flow requirements. There is little data that supports the removal of unused templates from the system or replacement with other templates. Commercial vendors of electronic documentation tools are incorporating existing HL7/LONIC standards for naming clinical documents but maybe the right solution is that clinical providers need to prioritize essential templates to reduce complexity. This approach would streamline documentation sharing amongst healthcare providers.
- Vawdrey, D. K. (2008), Assessing Usage Patterns of Electronic Clinical Documentation Templates, AMIA Annu Symp Proc. 2008; 2008: 758–762. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2656104/(Accessed on 18 Oct 2015)
- Payne TH, Kalus R, Zehner J. (2005), Evolution and use of a note classification scheme in an electronic medical record. AMIA Annu Symp Proc 2005:599-603. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1560646/(Accessed on 18 Oct 2015)