Joseph Kim, MD, MPH, MBA:
Your organization worked on an obesity quality improvement project, and 1 of the key interventions during this project was the development of a documentation shortcut to improve obesity care. Let us dive more deeply into that and discuss what you built. How was the documentation shortcut built? Can you give us a brief synopsis?

Sophia Kwon, MD:
We use EPIC at my institution, so we created what we call an obesity checklist. This is a smart phrase (or a dot phrase) that is a standardized template that can be included into any patient note. The beauty of it is that this checklist allows for efficiency and standardization in the questions that we ask regarding the topic, in this case obesity, for which the smart phrase is used.

Joseph Kim, MD, MPH, MBA:
The term smart phrase or dot phrase—we see it used and thrown around. Can you tell us a little bit more about what exactly it is? How is it created and used by healthcare professionals (HCPs)?

Sophia Kwon, MD:
A smart phrase is basically a standardized, premade template that can be easily added into any patient note once it has been shared with HCP users. It helps with standardizing the questions asked on a particular topic, and can act as a reminder for the specific questions that HCPs should pose to patients regarding the topic for which the smart phrase is created.

For example, ours is called the obesity checklist. All our resident HCPs were added as users of this smart phrase, and we have embedded it into our standardized clinic–patient notes. I think it can be very intuitive and simple to create and use a smart phrase. Further, the more comfortable you get with it, you can make it as elaborate as you would like. In my EHR system, smart phrases appear at the top left corner of my screen; they are right there where it says “my smart phrases.” If you click that button, you can select the option to create new smart phrase. This will give you a blank page where you can literally put in whatever you would like. Ours is a very simple checklist format, where users just have to answer simple yes or no questions in the checklist.

Joseph Kim, MD, MPH, MBA:
In terms of the things that can be added to a smart phrase, you mentioned you use a yes or no checklist option. Are there other patient variables and factors that could also be included in smart phrases?

Sophia Kwon, MD:
That is correct. If you select “add smart links”, there are lots of options in terms of items that you include. For example, you can include items that are specific to the patient for a specific note like their age, height, weight, and BMI.

Joseph Kim, MD, MPH, MBA:
There are a lot of ways to customize a smart phrase, but you kept it simple and straightforward. What was the overall intent behind your smart phrase when it was developed?

Sophia Kwon, MD:
In terms of the broad picture, we wanted to ensure that we were properly addressing and giving options to patients who are struggling with weight loss and/or obesity. The obesity checklist is a good reminder that we placed at the end of the patient note to bring up a topic that could easily have been left out of the conversation, especially in a clinic setting like ours. We are a federally qualified health center, so we see many patients who have an abundance of disease burden. Therefore, we wanted to make sure that we are addressing this very critical player in their overall health.

Joseph Kim, MD, MPH, MBA:
Let us talk about the specific elements of your smart phrase. What are the specific components of the obesity checklist that you developed?

Sophia Kwon, MD:
Our obesity checklist comprises 4 elements:

1. Have you placed a nutrition referral?
2. Have you placed a health coach referral?
3. Are there any medication interventions that were addressed with the patient?
4. Does the patient qualify for a bariatric surgery referral?

These were 4 very basic elements that we included in our smart phrase. Further, this was created via an abundance of guideline-based recommendations. For example, the United States Preventative Services Task Force, American College of Endocrinology, American Gastroenterological Association are recognized institutions that have clear guideline-based instructions on how to address obesity with patients. In addition, they outline what treatments can be offered to patient. These were the sources that we used to develop the checklist.

Joseph Kim, MD, MPH, MBA:
And was the intent to use the smart phrase at every visit? Was it intended to use just once a year? What was the intent behind when it should be used?

Sophia Kwon, MD
In an ideal world, our HCPs should be using this checklist at every patient visit. This is in every standardized progress note that we use with our continuity patients. Again, it is placed just right at the end of the patient note, below the assessment and plan sections. This placement is intentional. If obesity was not brought up naturally in conversations with patients, we can pose the checklist questions before ending the visit so that it is on the forefront of our and patients' minds alike.

Joseph Kim, MD, MPH, MBA:
As we think about the specific aspects of obesity care, such as improving nutrition or physical activity, are there any examples of other smart phrases or checklists that could drill deeper into addressing these more specific issues?

Sophia Kwon, MD:
That is a great question. Although our checklist is very succinct—just the bare bones of the questions that we wanted to ask patients—you can add more onto it. For example, when we talk about a nutrition or health coach referral, we want patients to know about the necessary 150 minutes of aerobic exercise per week, their options regarding cognitive behavioral therapy, and the individualized motivation needed for eating more whole foods and less processed foods. So others can really add whatever they would like into a smart phrase that can then be placed into patient instructions.

Another thing that I have done for our residents is create a list of the obesity medications that have been approved by the FDA for use. I included information about their contraindications, safety profiles, and what other medications these agents should not be combined with that our patients might be taking. This is really useful because once you have had the conversation about starting a medication for obesity, in just a couple of clicks, you can find a pretty comprehensive list about their available options.

Joseph Kim, MD, MPH, MBA:
When it comes to creating a smart phrase and informing staff about it, is there a formal training process you used to make them aware of this change? How did you train them so that they knew exactly what the checklist was and how to use it?

Sophia Kwon, MD:
Whenever there is an update that we want our residents to be informed about, we host a huddle at the beginning of our afternoon clinic sessions. We use this time to update our staff, so this was how we introduced the obesity checklist to them. They all have access to the patient progress note, so they would see the addition of the obesity checklist once it was added in. But we wanted them to know why it was there, how to utilize it, and how to broach this conversation with patients. They were given a rundown on how to use this checklist so that they were able to hit the ground running with this new addition on their patient progress note.

Joseph Kim, MD, MPH, MBA:
What was the guidance to staff on how to bring this subject up and walk patients through these questions?

Sophia Kwon, MD:
We host a lecture for all residents specifically on obesity care where we emphasize the type of questions that should be asked and the sensitivity with which to ask these questions. Obesity or weight loss can be a very sensitive or triggering topic for many patients. Therefore, we want to make sure that we do not cross the line of making them feel unheard or less than because of this health detriment. Rather, we want to pose these questions in a way that is bettering their health and bringing them to a place of better physicality. So residents sit in a lecture that is approximately 1 hour long and focuses on how to broach this topic with their patients.

Joseph Kim, MD, MPH, MBA:
In terms of issues like sustainability, are there any nudges or reminders to ensure this is being used and help those who might forget about it?

Sophia Kwon, MD:
There are asterisks that are placed within the smart phrase that any HCP must address or F2 through to complete the patient note. This is a kind of hard stop that we placed to remind residents to ask the obesity checklist questions before they sign the note.

Joseph Kim, MD, MPH, MBA:
Regarding that hard stop, what rule triggers it? Is it based on patients' BMI or “obesity” being in the problem list?

Sophia Kwon, MD:
The obesity checklist actually is added to every patients’ progress note, regardless of an obesity diagnosis. Sometimes it is easy to gloss over somebody's BMI and not even realize that this is a problem that might need to be broached. So the checklist acts as a catchall net to ensure we are properly documenting the people for whom this diagnosis qualifies.

Joseph Kim, MD, MPH, MBA:
Anytime we discuss EHRs and things like checklists in healthcare, there is always a risk that we could add to documentation burden, which often leads to HCP burnout and dissatisfaction. How did your team weigh these concerns and possibly address these issues as you developed and rolled out this checklist?

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

Joseph Kim, MD, MPH, MBA:
Are smart phrases or similar tools ever used to support printed patient education materials or follow-up instructions?

Sophia Kwon, MD:
All the time. The first example that comes to mind is  a smart phrase that we use for gastroesophageal reflux disease, which is a very common comorbidity that we see in patients with obesity. There are several lifestyle modifications that HCPs can suggest to help decrease their pill burden, so patients do not immediately jump to using H₂ antagonists or proton pump inhibitors. This is another smart phrase that I use in patient instructions. It takes just a couple of clicks to get a full paragraph on patient-based education to address this problem. I have found that patients appreciate this because it is comprehensive and in a language that is accessible and easy to understand. On the HCP side, it is nice because it is a very easy thing that we can do to help our patients.

Joseph Kim, MD, MPH, MBA:
It sounds like these documentation shortcuts are useful for HCPs doing the documenting, having conversations with patients, and printing education materials that the patients can take with them. Are there other examples of patient education or counseling materials that you have found to be useful with incorporating in a smart phrase to tailor or customize the instructions?

Sophia Kwon, MD:
Another example that comes to mind is that I started to notice that a lot of our patients were struggling with determining if they had available medication refills. They would call our clinic very concerned. So I created a smart phrase that incorporated a picture that I snipped from a generic pill bottle that illustrated with an arrow where the available refills are documented on the pill bottle.

It is these very small, practical obstacles that patients might run into that can be easily addressed with a smart phrase. I have smart phrases that help patients understand how to document their blood pressure, when to check their blood sugar, or what to do if they see a blood sugar below a certain number. All of this is important because it highlights the important topics that we would have covered during the patient interaction. Although they may forget about this conversation later, now they have it in writing. Further, it really was not difficult on my end to make sure that patients have this kind of resource because it was in a smart phrase that I had created previously.

Joseph Kim, MD, MPH, MBA:
Regarding the use of things like checklists and other smart phrases, lists, or tools, are there certain ones that are more popular and used frequently? Can you give us an example?

Sophia Kwon, MD:
I created a diabetes checklist for myself that is very similar to our obesity checklist because I wanted to make sure that I was addressing all the important questions that come with treating diabetes. As I was supervising residents, I noticed some were not asking patients about their fasting glucose or blood sugar levels 2 hours after a meal. So I introduced this diabetes checklist smart phrase that I made for myself and learned how popular it had become because of how helpful it was. It keeps HCPs on track in terms of the questions they should pose as well as the reasons why they should ask these questions.

It does not take a lot of thought. It is very efficient and standardized, so HCPs receive all the answers they need about patients’ diabetes. Therefore, I think any smart phrase that deals with a common disease pattern and with questions that are based on guideline recommendations is something that could be beneficial to any institution and could increase the popularity of its use.

Joseph Kim, MD, MPH, MBA:
Let’s talk about the challenges and lessons learned you experienced as we reflect on this quality improvement journey. What would you say were the big challenges you faced in developing this obesity checklist?

Sophia Kwon, MD:
I think, certainly in the beginning, there is a learning curve with teaching residents how to access and properly use the smart phrase as well as how to address obesity with patients. If we were to restart this project, it could be a good idea to provide something like a script for the residents to use outside of the regular lecture that they get on this topic. Even at a more systemic level, it would be great if we could incorporate something like an obesity clinic in our institution. This would be warranted for patients with high disease burden who also have obesity to dedicate a specific visit to address their obesity in depth and in detail.

Joseph Kim, MD, MPH, MBA:
Do you have any other advice for those, whether they are using any type of EHR, who want to implement this kind of smart phrasing to improve their obesity care?

Sophia Kwon, MD:
There are ways to become more proficient in this. The resources I tapped into included our EHR team that is affiliated with my institution. Then, looking into some other resources, you can become even more independent in your EHR management by signing up for e-learning courses. For example, EHR company has its own smart user program. These are things that I will continue to investigate because they are easy to learn from and the benefits seem to be exponential.

Joseph Kim, MD, MPH, MBA:
Within your organization, is there a process to encourage residents or other HCPs to come up with and present these kinds of ideas? Is there a formal process for that to happen?

Sophia Kwon, MD:
At Loma Linda University, specifically, there is an electronic health system–focused elective that can be taken by the seniors (second or third years). It is taught by one of our attendings from the pediatrics department, and it allows residents to become more proficient in their use of our EHR. Further, as a project that is a part of this elective, students must implement something like a smart phrase or standardized note template that they created. Then they must present it to their specialty, which is usually done in an outpatient clinic setting.

Joseph Kim, MD, MPH, MBA:
What kind of feedback have you received from those who use this obesity checklist?

Sophia Kwon, MD:
In terms of the feedback from the residents, I have heard incredibly positive things about adding this checklist to their note documentation process. They like that it allows them to recognize that there was possibly this gap in terms of broaching a conversation about a patient's BMI and obesity.

Because it is formulated as a checklist, it is easier to gently ease a patient into a conversation on obesity. Compared to when I first started working at the institution, I am now seeing a lot more patients who already have had this conversation with a prior attending or resident HCP. It is heartwarming to see that such a simple and small smart phrase tacked to the end of progress notes has had such a beneficial and tangible effect on our patient population.

Joseph Kim, MD, MPH, MBA:
Beyond the formal programming and training, have you found other resources that can help with developing and implementing smart phrases or similar tools?

Sophia Kwon, MD:
I did go on YouTube when I first started as an attending to learn about my institution’s EHR tips and tricks. I found a video that discussed 10 quick and easy tips on how to standardize your notes and make your note writing more efficient. I was not expecting much from that video, but I actually learned a lot. I gleaned things from it that I am still using in my practice. So I think if you are looking for ways to improve your use of an EHR system, resources are abundant and out there, outside of these formal learning courses.

Joseph Kim, MD, MPH, MBA:
With the emergence and increased use of generative artificial intelligence (AI) tools in healthcare, do you have any experience with using these tools to develop new ideas or refine your smart phrase functionalities?

Sophia Kwon, MD:
I have heard about these AI tools, and I know some previous coresidents and colleagues who are now incorporating these tools into their practice. I am not the most tech-savvy individual and I do have some caution with using AI. But I also see the huge potential it has in supporting healthcare delivery. At my institution, we have not had any interface yet with these tools; once it comes, I will certainly be eager to learn how it can be used to benefit my practice.

Sophia Kwon, MD:
I want to advocate for anyone who maybe is not familiar with this process. Again, I am 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 EHR—is something which we should take advantage of. I find that it really helps with the ease of documentation.

For those who are experiencing note bloat or documentation fatigue, this is something that can be taken advantage of to benefit one’s practice as well as the lives of our patients.