Patient and Public Information
No patient involved.
Curricular Design
Baylor College of Medicine’s Henry J.N. Taub Department of Emergency Medicine faculty interested in health policy, resident education, and administration and operations combined their unique skill sets to create a coding and charting curriculum. Using Kern’s 6-step approach to curriculum development, a widely applied to multiple specialties and training within medical education, we created a curriculum template for teaching the necessary charting and coding skills 8,9 To our knowledge, Kern’s framework has not been used to design a charting and coding curriculum previously. Table 1 summarizes Kern’s framework, outlines key aspects of our curricular design, and includes supporting educational evidence.
Table 1: Charting and Coding Curriculum Development Using Kern’s 6-Step Framework
Kern’s 6-Step Framework
|
Charting and Coding Curriculum
|
- Problem identification and general needs assessment
|
- Literature describing the best methods for training residents in this area is lacking
- Based upon results of a few studies3,6,7, charting and coding education during residency is well received and has the potential to improve confidence and performance
|
- Targeted needs assessment
|
- No formal training using TBL has been published for emergency medicine trainees
- Society of Academic Emergency Medicine and American Board of Emergency Medicine identify charting and coding as an area of improvement
-
|
- Goals and objectives
|
- Residents will describe the required elements to bill for the 6 major evaluation and management Current Procedural Terminology (CPT) codes for emergency medicine
- Residents will distinguish between the current payment system and newer payment modes
- Residents will propose billing charges of patient encounters.
|
- Educational strategies
|
- Team-based learning strategies
|
- Implementation
|
- Pre-curriculum survey to assess baseline comfort
- Residents will have 1 week to review the educational content at their own pace
- Delivery of curriculum
- Post-curriculum survey will include feedback
|
- Evaluating the effectiveness of the curriculum
|
- Evaluation of the immediate effect on improving skills will occur with a 1 week of session
|
Team Formation
Our residency program has four-to-five-hour didactics every Wednesday during the academic year. Due to restrictions secondary to the COVID-19 pandemic, all didactic sessions were conducted virtually. Our institution selected Zoom as its institutional platform for remote learning. We dedicated 3 hours of didactic time for the workshop. Learners were divided into heterogeneous, 4-6 member teams by facilitators to promote team development, using ability grouping based on post-graduate year of training. EM faculty members either served as facilitators or observed and shared input.
Description of Advance Preparation Resources
In preparation for the TBL session, faculty members selected a preparatory charting and coding document and developed the curricular readiness assurance test consisting of eight multiple-choice style questions (Appendix A). Prior to the TBL sessions, residents were expected to read the preparatory document (Appendix B) and complete a pre-curriculum survey. The preparatory document was freely available on line via the following link: http://www.drhem.com/education/wp-content/uploads/2015/04/Lets-Play-a-Game-Emergency-Medical-Documentation-Emily-Hirsh-MD.pdf.
Each resident then participated in the TBL activity outlined in Table 2. The sessions included the seven key TBL elements according to Haidet et al and were conducted using the standard TBL structure.19
Immediate Feedback
Faculty members provided immediate feedback after the group readiness assurance test in order to reinforce baseline knowledge and clarify discrepancies or misunderstandings. Answers to the readiness assurance test are included in Appendix C. A facilitator was also available for immediate feedback and clarification when during each case-based discussion.
Description of Team Application Activities
To develop team application activities, faculty members submitted de-identified cases which were used for case-based discussion during the traditional TBL small group sessions (Appendix D) accompanied by small-group exercise tasks (Appendix E). Session materials are available in the appendix section. The small-group exercise tasks met the 4S criteria (i.e., significant problem, same problem, specific choice, simultaneous reporting) of a typical TBL: teams worked on the same, significant problem, and selected specific choices simultaneously. 15 There were 4 sample charts and each was accompanied by an exercise task consisting of eight multiple-choice options for each question. Teams were instructed that there was one correct answer for each one which encouraged commitment to an answer choice. Teams moved through one vignette at the same time. Approximately 10 minutes per case were allowed for them to debate the answers within their teams, after which the team committed to an answer that was discussed with the facilitator. The facilitator then spent five minutes probing the team to highlight important and salient points in the cases. Afterwards, the correct answer was revealed and discussed. Answers to the small group cases and exercises are included in Appendix F and G, respectively.
Facilitation Schema
The TBL activity is outlined in Table 2. The sessions included the seven key TBL elements according to Haidet et al and were conducted using the standard TBL structure.19
Table 2: Session Timeline
TBL Component
|
Content
|
Description
|
Format
|
Planned Time
|
Pre-work
|
Preparatory document about topic distributed to residents via email
|
|
Online/Remote Learning
|
Outside of session
|
Introduction
|
|
Zoom opens, session begins, expectations set
|
Plenary
|
15 minutes
|
Readiness Assurance Test (RAT)
|
IRAT
|
8 multiple choice style questions completed individually
|
Individual readiness assurance test (8 questions)
|
Individual
|
15 minutes
|
GRAT
|
Same questions completed by teams in breakout rooms
|
Break out into teams
Team introductions
Team Readiness Assurance Test
|
Break out rooms
|
20 minutes
|
Discussion
|
Teams share their answers (“report out)”, followed by large group discussion of each answer; repeat for each question
|
Clarifications of IRAT/TRAT answers
|
Plenary
|
20 minutes
|
|
|
Break
|
Break
|
10 minutes
|
Application exercise
|
Team
|
Teams work on the same cases concurrently
|
Application cases in Batch 1
|
Break out rooms
|
35 minutes
|
Discussion
|
Teams simultaneously shared solution, followed by large group discussion for each case; repeated for each case
|
Application discussion 1
|
Plenary
|
15 minutes
|
|
|
Application cases in Batch 2
|
Break out rooms
|
35 minutes
|
|
|
Application discussion 2
|
Plenary
|
15 minutes
|
|
|
Break
|
Break
|
10 minutes
|
Conclusion
|
Facilitators summarize key points and conclude session
|
Closing
|
Plenary
|
20 minutes
|
Evaluation
The pre-curriculum and post-curriculum survey represented the primary method used to evaluate the effect of the curriculum on improving charting and coding skills. The pre-curriculum survey information was adopted from the previous year’s health policy curriculum survey, which contained self-reported comfort for the charting and coding module based on a 100-point visual analogue scale vis an anonymous SurveyMonkey distribution. The same survey was distributed after the curriculum with the addition of open-ended questions were included to assess strengths and areas for improvement.
Data for continuous variables were analyzed using the student t-test function of Microsoft Excel.