Optimizing neuro-ophthalmology documentation with Epic SmartPhrases: a strategic approach

The integration of SmartPhrases (SP), or “dot phrases,” in the Epic electronic medical record (EMR) system nomenclature stands out as a powerful tool in the constantly evolving landscape of healthcare documentation [1]. SP are keywords that can be pre-programmed by Epic EMR users that allow them to auto-populate necessary information into a patient’s chart with the intention to improve efficiency in patient care. SP has shown promising results across various medical disciplines [1, 2]. This article explores a way of implementing SP in the context of neuro-ophthalmology, focusing on the creation of specialized phrases for common presentations and their potential to optimize charting practices, especially when working with residents and medical students.

The impact of using SP is most prominent for conditions that have specific diagnostic criteria and should be used to import relevant information from the clinical history that satisfies the diagnostic criteria. An example would be in the assessment of idiopathic intracranial hypertension (IIH). We have created a specific IIH SP, provided in the supplementary material, that can import demographics, labs, and imaging results for each of the modified Dandy criteria for IIH.

A second use of SP is when assessing conditions with scoring systems, where each item contributes to a global score for diagnosis or disease progression. An example provided in the supplementary material is the clinical activity score (CAS) used for thyroid eye disease (TED) assessment [3]. We created an SP that would pre-populate the criteria on the scale so that the user may simply evaluate for each of these items, and the total score would be calculated accordingly.

The third case we demonstrated in the supplementary material is diagnosing primary diseases that depend on ruling out other aetiologies. For secondary causes of optic neuropathy when a patient is referred to our Neuro-Ophthalmology clinic from a glaucoma specialist, the SP will provide an extensive differential diagnosis of optic neuropathy aetiologies and will import relevant information from the patient’s chart pertaining to that differential.

A fourth case of the SP in our clinic is “call,” which populates messages to technicians, residents, and fellows the usual and customary practice for dealing with normal and abnormal laboratory and imaging results. The dot phrase (“call”) populates the note as “Please call the patient, document a note in Epic, and schedule a follow up.”

The adoption of Epic SP in clinical neuro-ophthalmology has several advantages, aligning with broader observations across medical specialties [1, 2]:

1. Easier Documentation and Teaching: SP provides a shortcut for inserting frequently used text, thereby streamlining the documentation process, especially in the case of mentoring residents and medical students new to neuro-ophthalmic conditions. In the realm of neuro-ophthalmology, this translates to more efficient documentation of patient symptom progression, signs, and diagnosis using established clinical criteria [1, 4].

2. Increased Efficiency: By collecting and creating SP, healthcare providers can efficiently access and document patient information, improving duration of pre-charting prior visit notes. This proves particularly beneficial in time-sensitive assessments, such as ruling out acute optic neuropathy etiologies [2].

3. Increased Face-to-Face time: With the use of SP, providers can auto-populate the necessary questions and patient information in real-time during the encounter. This translates into additional time for clinicians to focus on the patient interaction, answer questions, and improve by the chair or bed-side care.

4. Holistic and Quality Patient Care: SP acts as valuable aids for maintaining consistency in recorded assessments across multiple providers from various specialties. The use of SP can contribute to the creation of more comprehensive and chronologically accurate clinical documentation, especially in neuro-ophthalmology, where precise and complete patient histories are paramount to the diagnosis.

Epic SP, although serving as a significant and evolutionary creation in the advancement of patient care, may also present with important challenges to consider in the long-term:

1. Proliferation of Redundant Dot phrases: Without proper oversight, EMR users may create duplicate SP for the same content, or SP with outdated clinical information. As the EMR does not check for duplicate SP, redundant information may be uploaded to the chart multiple times if different SP are used by users [1]. With this in mind, we created a standardized SP with the intent to encourage collaboration, pull information from the same data set, and reduce the repetition of dot phrases.

2. Minor Reduction in Time for Note Writing: Considering the extensive medical history many of our patients may have, it is important to note that the overall time dedicated to completing a patient note may not be reduced. Prior studies have showcased no significant effect on the time to complete notes with the use of dot phrases, which is a factor to consider when creating future SP [5].

3. Potential for Higher Billing: With the quick note-filling features that are possible with SP comes the temptation to document a higher level of service and check off boxes due to convenience and speed. Perotte et al. conducted a study observing the effects of dot phrases in a local emergency department (ED) and noted that CPT coding levels for billing were significantly higher when more dot phrases were utilized, informing us that fair evaluation of diagnostic criteria must continue to be implemented by physicians in the setting of SP usage [5].

Clinicians should be aware of the proliferation and use of SP in Neuro-ophthalmology. We have developed specialized dot phrases for common presentations, such as the Clinical Activity Score for Thyroid Eye Disease (TED), the Diagnostic Approach for Idiopathic Intracranial Hypertension (IIH), follow-up messaging, and the differential for Optic Neuropathy. We provide these SP templates at no cost to other Epic EMR users with the hope that it will spark interest in sharing SP across Neuro-ophthalmology. Neuro-Ophthalmology evaluation requires comprehensive history taking and SP allows us to focus on the relevant history, symptoms, and specific lab work/imaging tailored to the diagnosis. Future work is needed to determine if our work on SP for TED, IIH, messaging, and Optic Neuropathy can be generalized and improve outcomes (speed, efficiency, clinic volume, billing, and coding compliance).

Author contributions

SBG, PS, SAA, OAD, and AGL all designed the work that led to the submission, created supplemental images, and/or played an important role in interpreting the results. All contributed to drafting or revising the manuscript. All approved the final version and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Competing interests

Dr. Andrew Lee has the following interests to declare: Amgen (speaker’s bureau), Alexion (speaker’s bureau), Viridian (Advisory Board), Stoke, AstraZeneca, and Bristol Mayers Squibb. The other authors report no conflicts of interest.

Supplementary information

The online version contains supplementary material available at 10.1038/s41433-024-03367-9.