559 - Customization of Electronic Medical Record Autotexts to Improve Documentation and Standardize Inpatient Pediatric Asthma Care

Publication Number: 559.4457

Kara L. Oliver, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, AMHERST, NY, United States; Noah Stanco, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Buffalo, NY, United States; Mary Daley, University at Buffalo, Depew, NY, United States; Hend Abd El Baky, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Buffalo, NY, United States; Laura Nelson, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Buffalo, NY, United States; Kendria C. Hall, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Buffalo, NY, United States

Background: Asthma is a prevalent childhood illness, with over 60,000 pediatric hospitalizations and 200 deaths in the US in 2020. Despite national guidelines for management from the National Asthma Education and Prevention Program, and many standardized scores to guide inpatient treatment, such as the Pediatric Asthma Score (PAS), we found limited adherence to either at our institution. To address these gaps, we implemented a new asthma pathway in September 2023 with complimentary autotexts, as previous research has shown the effectiveness of autotexts in standardizing clinical care and provider documentation. Autotexts were created to prompt documentation of the following key items on admission: 1) PAS 2) Asthma Control Test (ACT) score 3) standardized asthma history questions and 4) need for subspecialty consult, all found to be sub-optimally documented.

Objective: To increase documentation of each of items 1-4 to 70% in asthma history and physicals (H&Ps) over 6 months.

Design/Methods: We introduced a set of autotexts in the electronic medical record for use in asthma H&Ps to prompt documentation of items 1-4. The primary process measure was the ratio of autotext executions to admissions, assessed monthly by run chart. All H&Ps of asthma patients during the pre-intervention period (April-June 2023) and evaluation periods of two Plan-Do-Study-Act (PDSA) cycles (PDSA 1, November 2023-January 2024 and PDSA 2, April-June 2024) were assessed for documentation of items 1-4 and character count (as a balancing measure). Routine education was implemented during PDSA #1 and augmented by the implementation of “badge buddies” and workstation reminders during PDSA #2. Feedback was solicited via resident physician surveys.

Results: Autotext execution tracking showed sustained adoption of autotexts (Fig.1). PAS documentation increased significantly from 8% pre-intervention to 64% (PDSA 1) and then 83% (PDSA 2, Fig. 2). Standard asthma history questions also showed significantly increased documentation across both PDSAs but fell short of goal (36% during PDSA 2). ACT score and need for consult failed to sustain an initial significant increase through PDSA 2. Median character count initially remained steady but showed a significant increase during PDSA 2(Fig. 3).

Conclusion(s): A set of standard autotexts for asthma H&Ps increased utilization of PAS and standard asthma history questions, but modestly increased character count. New methods to increase adoption and meet the remaining goals will be pursued in future PDSA cycles, including introduction of a non-interruptive alert and refinement of autotexts for increased ease of use.

Autotext Executions as % of Asthma Admissions By Month
Fig. 1: Run chart of the executions of each autotext category - PAS, plan and control - as a percentage of total asthma admissions. Select interventions are labeled. Note that the evaluation periods of PDSA 1 and PDSA 2 comprise the last three months of the respective period after implementing appropriate interventions. The median as well as monthly values are depicted for each category of autotext, along with the goal of 70% executions, reached for all autotexts at the end of PDSA 2.

Change in Documentation Percentage
Fig. 2: Change in documentation of key items during the pre-intervention period and the set evaluation periods for
PDSA 1 and PDSA 2. *, **, *** denote statistically significant difference compared to the pre-intervention period at the p < 0.05, 0.01, 0.001 levels respectively, determined by chi squared or Fisher's Exact test as appropriate. PTEAMF denotes a set of 6 standard asthma history questions, with documentation considered adequate when answers to at least 5 out of 6 questions were documented in the H&P.

Change in Median Character Count
Fig. 3: Median character count in the pre-intervention period, PDSA#1, and PDSA #2.
*** denotes statistically significant difference compared to the pre-intervention period at the p < 0.001 level determined by Mann-Whitney U test.