THE DIGITAL REVOLUTION
Charting Made Easy : Why Wait for AI Solutions When Traditional Computer Software Options are Already Available ?
The Artificial Intelligence ( AI ) train has left the station . As a physician with only an average grasp of the possibilities of the technology , it is not difficult for me to envision a future where AI manages my results inbox , sends me appropriate prescriptions to co-sign and contacts patients to schedule future appointments . I can imagine a labor and delivery unit where the fetal heart rate tracings are being scrutinized in real-time by AI , which would then suggest to the staff when fetal or maternal interventions are recommended . It ’ s a new frontier in medicine — one where my responsibilities may be drastically different in the next decade or two .
Instead of focusing on the what-ifs , let ’ s focus on the here and now . We all want to provide excellent patient care , while also avoiding burnout . We want to be more efficient in our charting . We want improved outcomes and fewer clicks . We want minimal patient wait times . We want to go home after seeing the last patient , instead of hanging around after hours to complete progress notes and sign open encounters . AI may help us achieve all of those goals down the road , but we ’ re not there yet . For many of us , we simply need to better utilize the tools that we already have at our disposal .
One such tool is the SmartSet application within the Epic electronic medical record ( EMR ) software . As defined by Epic , “ SmartSets help clinicians work through a visit efficiently using your organization ’ s recommendations .” As a Physician Builder , I am responsible for creating new SmartSets and updating those that are already in production . Over the last four years , my main focus has been to create SmartSets for prenatal appointments and
10 LOUISVILLE MEDICINE by NICHOLAS RYAN , MD postpartum visits , along with updating our existing one for annual exams ( these three visit types account for over 80 % of my daily appointment slots ). Utilizing these tools in the outpatient setting has drastically reduced my charting time , while also improving my billing accuracy and documentation detail . Patients very rarely wait to be seen . I don ’ t have to rely on office staff to place lab or imaging orders . All of my charts are closed by the end of the day .
( Before I lose readers who are outside of the women ’ s health realm , just a quick note to state that SmartSets can be built for most fields of medicine . If you find yourself repeating a certain charting task , there may be a role for SmartSets in your workflow . Contact your organization ’ s Epic representative to see if a Physician Builder exists for your department .)
Due to the fact that there are specific guidelines for prenatal care put forth by both the American College of Obstetricians and Gynecologists ( ACOG ) and the American Academy of Pediatrics ( AAP ), outpatient obstetric visits can be quite predictable . Additionally , our healthcare system has utilized a Standardization Committee that looks to streamline workflow practices . This collection of guidelines can be encoded into a SmartSet , resulting in a tool that — with one click — suggests both primary and secondary diagnoses codes , auto-populates a progress note , chooses the appropriate follow up time period and level of service ( LOS ) code and pre-checks the gestational age-appropriate lab , imaging , vaccine and medication orders .
Why is this useful ? There are myriad reasons . For starters , the SmartSet reduces clicks and saves the end user time . It ’ s hard not to hear about the rates of provider burnout . While this doesn ’ t completely eliminate the problem , it can be thought of as part of the solution . Secondly , the SmartSet streamlines documentation across