Improving Provider Documentation Using a Pediatric Automated Documentation Assistance Tool

Clinical documentation improvement is critical for pediatric care, yet leveraging electronic health record (EHR) tools for this population is not well established. We aimed to adapt and implement a real-time, automated documentation assistance tool (AutoDx) to decrease clinical documentation integrity (CDI) coding queries and improve perceived ease of practice for pediatric inpatient providers. In this quality improvement study at an urban academic pediatric hospital, we adapted and implemented AutoDx for pediatric use by developing and validating pediatric-specific logic rules to alert providers to potential diagnoses based on EHR data. The primary outcome was the rate of CDI queries per 1,000 discharges for targeted diagnoses, aiming for a 50% reduction over a 5-month implementation period compared with a 12-month baseline. Secondary outcomes included provider-surveyed ease of practice, with a goal of a 25% improvement, and tool uptake. The aggregate rate of targeted CDI queries decreased by 58% postimplementation, from 80.7 to 33.9 per 1,000 discharges (p < 0.001). Moreover, analysis by interrupted time series demonstrated an immediate 45.5% reduction in the rate of coding queries (p = 0.028) following the implementation of the tool. The rate of queries for nontargeted diagnoses remained unchanged. Tool adoption increased steadily throughout the study period. While provider-reported time spent on queries did not significantly decrease, a majority of survey respondents (59%) perceived receiving fewer queries, and 46% agreed the tool made it easier to provide quality care. Implementation of a real-time, automated documentation support tool in a pediatric inpatient setting significantly reduced CDI coding queries for targeted diagnoses. Despite a “task substitution” effect where perceived workload did not decrease, the tool improved perceived ease of practice, demonstrating that targeted EHR interventions can enhance documentation accuracy and efficiency in pediatrics.