Quality Improvement in Obesity Care: How to Implement Documentation Shortcut

Joe Kim: Thank you so much, Dr Kwan, for joining us for this interview. And to start us off, why don't you go ahead and tell us about yourself as well as tell us about your role within the organization?

Sophia Kwan: Thank you for having me, Dr Kim. My name is Sophia Kwan. I'm a teaching-attending at the faculty of Riverside University Health System, as well as Loma Linda University for the Internal Medicine department, and I get to work with residents from both institutions. And I work mostly in the clinic setting, but also a couple of weeks throughout the year in the in-patient setting.

Joe Kim: So your organization had worked on an obesity quality improvement project, and during that work, one of the key interventions was the development of a documentation shortcut to improve obesity care. So let's dive more into that and talk about what exactly did you build and how is that built? And just give us a brief synopsis of the electronic intervention that was created.

Sophia Kwan: Sure. So we use EPIC at our institution, and we basically created what we call an obesity checklist. And this is a smart phrase or a dot phrase that is like a standardized template that you can put into any note. I think the beauty of it is that it allows for efficiency and for standardization in the questions that are asked regarding the topic that the smart phrase is used for.

Joe Kim: So the term smart phrase or dot phrase, we see it used, we see it sort of thrown around. Tell us a little bit more about what exactly is it? How is it created? How is it used by clinicians?

Sophia Kwan: Yes. So a smart phrase is basically the standardized premade template that can be easily added into any patient note once that smart phrase has been shared with you, and you are added as a user for that smart phrase. So again, it helps with the standardization and the questions asked, and it can even act as a reminder for the specific questions that you want to pose to a patient regarding the topic that the smart phrase is created for. So, for example, again, ours is called the Obesity Checklist. And all of our resident physicians have been added as users to this smart phrase and we've embedded this as well into the standardized clinic notes. And I think, you know, it can be very intuitive and simple to create and to use and the more comfortable you become with it, you can make it as elaborate as you would like. For me, it shows up on the top left corner of the screen under EPIC, and it's right there where it says ‘my smart phrases’. Once you click that, you can say, ‘create new smart phrase’ and it gives you a blank page where you can literally put in whatever you'd like. Ours is a very simple checklist kind of format. And we added, if you press on ‘enter smart links’, you can have the option of creating the smart phrase that has a yes or no option to the questions or the checklist that you've created.

Joe Kim: So in terms of the things that can be added to a smart phrase, you've mentioned a smart link, like a yes or no option. There are also other perhaps patient variables and factors like that that could also be included in smart phrases. Is that correct?

Sophia Kwan: That's correct. So if you click on the ‘add smart links’, there are literally probably hundreds of thousands of options of things that you include. You can even include things that are specific to that patient for that note. For example, if you wanted to, you could probably add their age, height, weight, BMI to be included as part of that obesity checklist.

Joe Kim: So a lot of ways to customize. You all kept it, I would say, fairly simple and straightforward. What was the overall intent behind the smart phrase when it was developed?

Sophia Kwan: I think, broad picture, we wanted to make sure that we were properly addressing and giving options for patients who are struggling with weight loss and with obesity. It was a good reminder that we placed at the end of the note to bring up a topic that might be easily left out in conversation, especially in a clinic setting like ours. We’re an FQHC, so we see many patients who have an abundance of disease burden. So we wanted to make sure that we are addressing this very critical player in their health.

Joe Kim: So let's talk about the elements that were chosen to be included in the smart phrase. What were the actual pieces of the smart phrase that you all developed?

Sophia Kwan: Yes. So we have 4 elements to our obesity checklist: have you placed a nutrition referral? Have you placed a health coach referral? Do you have medication interventions that were addressed with the patient? And does this patient qualify for a bariatric surgery referral? So these were 4 very basic questions, 4 basic elements that we included into the smart phrase. But really this is derived from an abundance of guideline-based recommendations. For example, the USPSTF, the American College of Endocrinology, the American Gastroenterological Association, these very big institutions that have very clear guideline-based instructions on how to address obesity and what kind of offers can be made to the patient. These were the sources that we use to create those 4 guidelines of the checklist.

Joe Kim: And was the intent to use the smart phrase at every visit, was it intended to use just like once a year? What was the intent behind when it should be used?

Sophia Kwan: Ideally, we should be using this at every visit. So this is in every standardized progress note that we have for our continuity patients. And it's, again, placed just right at the end below the assessment and plan, so that if it wasn't brought up in the conversation during the interview, we're able to pose this question so that it's on the forefront of our minds as well as our patient's minds.

Joe Kim: Now, when it comes to creating a smart phrase and telling your residents and other staff about it, is there either a formal training process, a way to make them aware of this? How is this socialized with them so that they knew exactly what it was and how they should use it?

Sophia Kwan: Whenever there's an update in our clinic setting that we want residents to be informed of, we do a huddle at the beginning of the afternoon clinic sessions, and we use that time to update our residents. So this was how we introduced this obesity checklist to them. They all have access to the progress note, so they would have seen the addition of the obesity checklist because it's been added in, but we wanted them to know why it's there, how to utilize it, and how to broach this conversation with our patients. So they were given a rundown on how to use this template so that they were able to hit the ground running with this new addition on their progress notes.

Joe Kim: And you mentioned in terms of how to bring this up to patients, I could imagine someone just sort of quickly running through the checklist vs having a script that maybe they kind of run through. So what was the guidance for the staff and the residents on how they should bring this up and walk the patient through these various questions?

Sophia Kwan: We actually have a lecture for all of the residents specifically on obesity care and we emphasize the type of questions that should be asked as well as the sensitivity with which these questions are asked. You know, it can be a very sensitive or triggering topic for many patients. We want to make sure that we don't cross the line of making them feel unheard or making them feel less-than because of this health detriment, but we really want to pose it in a way that's bettering their health and bringing them to a place of a better physicality. So they actually do get a lecture, about a 1-hour lecture on obesity and how to broach these topics with their patients.

Joe Kim: And anytime we talk about electronic records and things like checklists, there's always that risk that we might be adding to the documentation burden that so often leads to things like burnout and provider dissatisfaction. How did your team weigh these concerns and possibly address these issues as you developed and rolled out this checklist?

Sophia Kwan: Yes, I certainly know about note bloat and can sympathize with the burnout of documentation. So we really tried to create a smart phrase that was incredibly succinct. We touched on it before but there were several guidelines, several institution-based guidelines that we were incorporating into these 4 basic questions. But we were able to create 4 simplistic questions that are just at the end of the note, to prevent the note bloat that could arise when we're trying to create a major systemic change.

Joe Kim: And regarding the use of things like checklists and other smart phrases and smart lists and all the other smart tools that are incorporated, are there certain ones that are very popular, perhaps used very frequently? Can you just give us maybe an example of some of those?

Sophia Kwan: Yes, this might be a little bit of a sidebar, but I created a diabetes checklist very similar to the obesity checklist, and I just created it for myself because I wanted to make sure that I was hitting all of the important questions. And as I was chiefing residents and I noticed if they weren't asking about their fasting glucose or what their blood sugars were 2 hours after a meal, I just kind of introduced this diabetes checklist smart phrase that I had made for myself and realized the popularity of it because it helps keep you on track in terms of the questions that you'd like to pose, as well as the reasons why you're asking these questions. And it doesn't take a lot of thought. It's very efficient and it's standardized, so you have all of the answers about their diabetes. So I think any smart phrase that deals with a very common disease pattern, with questions that are based on guideline practices, is something that could be beneficial to anybody and could increase the popularity of its use.

Joe Kim: Great. And in terms of issues such as sustainability, ensuring that people remember to use this, were there things that were done, either nudges, reminders or any other examples of ways to sort of ensure that, ‘Hey, this tool has now been created, let's make sure that it's being used’ and to help those who might be forgetting?

Sophia Kwan: So again, it's placed at the end of our progress notes, and I should mention that there are asterisks that are placed within the smart phrase. So, as you know, before you sign a note, you have to get rid of all of the asterisks or F2 through the asterisks, and that's just kind of a stop, like a hard stop that we placed to remind the resident physicians, ‘Hey, you know, make sure that you ask these questions before you sign the note.’

Joe Kim: So regarding that hard stop, what was the rule that triggered that? Was it based on the patient's BMI or based on obesity being on the problem list or something else?

Sophia Kwan: No. So actually this is an obesity checklist that is added to every single progress note, regardless of whether or not they qualify under that diagnosis of obesity. So what's helpful is that, you know, sometimes it's easy to just kind of gloss over somebody's BMI and not even realize that this is a problem that needs to be broached. And so it kind of acted as a catchall net to make sure that we were documenting properly the people for whom this diagnosis qualifies.

Joe Kim: Great. And then let's talk about some of the challenges as well as lessons learned as you reflect back on this sort of journey. You've provided examples of other smart phrases, and I'm sure people create their own as well. What would you say were some of the big challenges that you faced when developing this obesity checklist?

Sophia Kwan: In the beginning, there's a bit of a learning curve with teaching residents how to access the smart phrase, how to properly use the smart phrase and to address it in the first place. I think if we were to try this again from the beginning, it would be a good idea to maybe provide something like a script for the residents to use, like you had previously mentioned, outside of the regular lecture that they get on this topic. And even at maybe a more systemic level, it would be great if we could incorporate something like an obesity clinic, which would be warranted for patients with high disease burden who also have obesity, in order to dedicate a specific visit to address their obesity in depth and in detail.

Joe Kim: And let's talk now about advice for others who might, whether they're using EPIC or really any type of electronic health record that has this kind of smart phrasing or dot phrase capabilities. So, advice that you would give others when it comes to those interested in developing tools or just documentation efficiency around improving obesity care?

Sophia Kwan: Yes, I think there are definitely ways to become more proficient. The resources that I've tapped into were the EPIC team or the EHR team that is affiliated with my institution. This includes your own institution’s EHR training team. And looking into some other resources, it looks like you can become even more independent in your EHR management by signing up for these e-learning courses, or EPIC has their smart user program. And so these are things that I'll be definitely looking into because they seem very easy to learn from and the benefits seem pretty exponential.

Joe Kim: And beyond the formal programs and the staff that you've mentioned, have you found other resources, whether they are websites or other examples where you could either see like, ‘Hey, here are some ideas for smart phrases or similar’, or ‘Here's maybe resources on how to even create and build one, or how to modify one’? Like are there things like that that you found to be helpful?

Sophia Kwan: I did go on YouTube when I first started as an attending to look at my specific EHR’s tips and tricks, and I found 1 video that was like 10 quick and easy tips on how to standardize your notes and make your note writing more efficient. And I wasn't expecting much from that video, but I actually learned a lot of things, and I gleaned things that I'm still using in my practice. So I think if you're looking for ways to improve your use of an EHR system, it is abundant and it is out there, outside of these formal learning courses.

Joe Kim: And I'm wondering if within the organization, is there a process to encourage residents or others to come up with these kinds of ideas, whether it's a smart phrase or really any other sort of tip or trick, and then to present those ideas to others, maybe to share them. Is there a formal way that that happens?

Sophia Kwan: Yes, I know that at Loma Linda University specifically, there was an electronic health system learning elective that could be taken by the seniors, so if you're a second year or third year. It was taught by one of our own attendings from the pediatrics department, and it allowed residents to become more proficient in their use of EPIC and as a project, which is part of the elective, kind of like a capstone, you had to implement something like a smart phrase or a standardized note template that you had created yourself, and teach it and present it to your specialty. And these were usually in an outpatient clinic setting.

Joe Kim: Now, with the emergence and the use of popular generative AI tools and others, I'm wondering if you've had any experience playing around with those, either to get ideas for new smart phrases or even to maybe refine or sort of like, ‘How can we add or incorporate these other functionalities into smart phrases?’ Any experience with those?

Sophia Kwan: Yes, I’ve heard of these AI tools that are coming in, and I know some of my previous co-residents and colleagues at different institutions are now incorporating them into their practice. I think, like many people, I'm not the most tech savvy and I feel a little bit of caution with the AI systems but see their huge potential. So where I'm currently working, we haven't had any interface with these AI tools, but once it comes, I'll certainly be eager to learn how it can benefit us in our efficiency.

Joe Kim: And let's now talk about some other topics related to the smart phrases. You sort of think back, reflect back on the whole experience, as well as even its current use now, what kind of feedback, if any, did you receive from those who used this obesity checklist and did that feedback come only from the residents? Did it also come from any of the attendings or from any of the other staff?

Sophia Kwan: So in terms of the feedback from the resident physicians, I've heard, surprisingly, very positive things about adding to their note documentation process, only because it allows them to recognize that there was possibly this gap in terms of broaching a patient's BMI and obesity. And because it is formulated as a checklist, it's easy to kind of ease a patient into the topic and to broach the topic gently and to make sure that these guideline based questions are being asked. I would say that when I first started working at the institution, compared to now, I am seeing a lot more patients who have had this conversation already. When I see them in a continuity clinic, they've had this conversation with a prior attending that had a visit with them or with the resident physician. So it is kind of heartwarming to see that such a simple and small smart phrase tagged on to the end of a progress note has had such a beneficial and tangible effect on our patient population.

Joe Kim: So, as we think about specific aspects of obesity care, like improving nutrition or perhaps physical activity, can you think of examples, whether it's a smart phrase or even another type of checklist, that could help drill down deeper into like, ‘Hey, let's really address this issue of healthy eating and nutrition’ and guide and help that patient during that conversation?

Sophia Kwan: That's a great question. I think our checklist is, again, very succinct, just the bare bones of the questions that we'd like to ask. But when you talk about a nutrition referral, when you talk about a health coach referral, what you're really implying is that you want them to know about the 150 minutes of exercise, of aerobic exercise per week, you want them to know about the options of cognitive behavioral therapy, and individualized motivation when it comes to more whole foods and less processed foods. You can really add whatever you would like into a smart phrase that you can place into patient instructions. So another thing that I've done for residents is create a list of the obesity medications that are FDA approved for use, what their contraindications are, what their side effects are, what medications should not be combined with other medications that the patient might be on. And this is really useful because once you've had the conversation about possibly starting somebody on a medication for their obesity, just a couple of clicks and you can pull up a pretty comprehensive list about what the options are that are available for them and have a discussion about what the side effects would be, what they need to look out for, when the follow up time would be, and things like that.

Joe Kim: That's great to hear. Are smart phrases or similar types of dot phrase tools ever used when you want to print, say, patient education materials or follow up instructions or anything along those lines?

Sophia Kwan: All the time. So the first one that just popped to mind is that there is a smart phrase or a dot phrase for GERD, which is a very common comorbidity that we see in patients that also have obesity on their health issues list. And there are several lifestyle modifications that you can use to decrease their pill burden, so you don't immediately jump to using their Pepcid or their PPIs. And so that's another smart phrase that I put into the patient instructions and say, ‘Hey, try this for a little bit.’ And again, it's a couple of clicks and you have a full paragraph on patient-based education to address this problem. And I've found that patients appreciate this on their end because it is comprehensive, it is in a language that is accessible and easy to understand. And on the physician side, it's nice because it's a very easy thing that you can do to help your patients out.

Joe Kim: So it sounds like these documentation shortcuts are useful both for the clinician doing the documenting, having the conversations with the patients, but then also with any printed materials or things that the patients may take with them. Are there other examples of patient education, patient counseling materials that you can think of, that you have found to be useful in terms of, like, incorporating this phrase has helped me either tailor or customize the instructions for whatever that patient might need?

Sophia Kwan: Yes, I just did this a couple of weeks ago, but another thing that pops into mind is I've noticed that a lot of patients were struggling with identifying if they have medication refills, and they would call our clinic very concerned. And I just created a smart phrase that incorporated a picture that I had snipped of a generic pill bottle that had an arrow pointing to where the refills is documented on the pill bottle. And that was really appreciated. So, you know, it's these very small, practical obstacles that patients might run into that can be easily addressed very quickly with the use of something like a smart phrase to help for them to take home and have on their printed paperwork that they hang up on their fridge. Even, I have smart phrases that say, this is how you document your blood pressure, this is the times that you should check your blood sugars, this is what you should do if you see a blood sugar below this number. And all of this is very important because it highlights the important topics that we covered during the interview, during the patient interaction that they might have forgotten, but now they have in writing. And it really wasn't difficult on my end to make sure that they have this kind of resource, because it was in a smart phrase that I had created previously.

Joe Kim: Well, this has been a great conversation. I want to thank you, Dr Kwan, so much for taking the time to share with us your insights as well as to teach this audience about smart phrases. Is there anything that we have left off that you would like to make sure we include, or any other sort of thoughts or nuggets of information that perhaps we didn't get to?

Sophia Kwan: I do want to just advocate for anyone who maybe is not familiar with this process. Again, I'm really not the most tech savvy person in the world, but I think the process of using a tool like this that is already built into the electronic health record is something that we should take advantage of. It really helps with the ease of documentation. So if there are people that feel like they are experiencing note bloat or note fatigue or documentation fatigue, this is something that we can really take advantage of and use it to benefit our practice and benefit the lives of our patients as well.