CPAP Module 18, Section 3: Templates and Smart Phrases for PAs
MODULE 18: WORKING WITH EMRS & EHRS

Section 3: Templates and Smart Phrases for PAs

A Practical Guide to Building and Utilizing EHR Customization Tools to Automate High-Quality Clinical Narratives.

SECTION 18.3

Templates and Smart Phrases: The Automation Advantage

From Repetitive Typing to Strategic, High-Speed Documentation.

18.3.1 The “Why”: Efficiency Is a Form of Patient Advocacy

In your work as a PA specialist, you will quickly discover a fundamental truth: the majority of your cases for a given drug class follow a predictable pattern. A request for an SGLT2 inhibitor will almost always require an A1c, a confirmation of a Type 2 Diabetes diagnosis, and a list of previously tried oral agents. A request for a biologic for rheumatoid arthritis will always require evidence of DMARD failure. You will find yourself typing the same sentences, the same justifications, and the same clinical data points dozens of times a day. Each instance of this repetitive typing is not just a drain on your time and a source of potential typographical errors; it is a delay in patient care.

This is where the mastery of EHR customization tools becomes a professional and ethical imperative. Tools like SmartPhrases (in Epic), Autotext (in Cerner), and other template systems are not merely “shortcuts” for lazy typists. They are powerful instruments for process engineering. By investing time to build a robust library of templates, you are front-loading the cognitive work of organizing a clinical narrative. You are creating a standardized, best-practice format for clinical justification that ensures every submission from you or your team is complete, consistent, and structured in the precise way that payers need to see the information for a rapid approval.

This section will reframe your view of documentation. It is not a passive recording of facts; it is an active act of persuasion. Your goal is to build a clinical case so clear, so well-supported, and so perfectly aligned with the payer’s criteria that a denial becomes virtually impossible. Templates and SmartPhrases are the blueprints you will use to construct these airtight clinical arguments with unparalleled speed and accuracy. Mastering this skill is the final step in transitioning from a clinical data hunter to a master clinical case builder, turning hours of manual work into minutes of strategic, automated, and highly effective patient advocacy.

Retail Pharmacist Analogy: Engineering the Perfect SIG

In your retail practice, you never type out the full instructions for a prescription. Your pharmacy software uses a sophisticated system of SIG codes and shortcuts. When a prescription for amoxicillin comes in with the instruction “Take one capsule by mouth three times a day for ten days,” you don’t type all 54 of those characters. You type 1 po tid 10d.

Why? It’s not just about speed. It’s about precision, standardization, and safety.

  • Standardization: Every label for that instruction looks identical, reducing patient confusion.
  • Accuracy: It prevents typos like “tmes” instead of “times” or “dat” instead of “day.”
  • Embedded Logic: Your system automatically calculates the correct quantity (30 capsules) and days’ supply (10) from that simple code. It might also automatically flag it for a “shake well” or “take with food” auxiliary label.

A SmartPhrase or PA template is the clinical documentation equivalent of a highly advanced SIG code. Typing .PA_Ozempic into a note is like typing 1 po qd. It’s a simple trigger that unleashes a pre-built structure of clinical logic, data placeholders, and required narrative elements, ensuring the final output is perfect every time. You have spent your career mastering the language of SIG codes to ensure dispensing safety and efficiency. You will now apply that exact same principle—encoding complex requirements into a simple, reusable format—to the world of clinical justification.

18.3.2 The Anatomy of a Perfect Prior Authorization Template

A powerful PA template is more than just a block of text. It is a structured, intelligent document designed to guide your review, auto-populate data, and present the final case in a logical, easy-to-review format for the payer. A world-class template is built from five essential components.

Masterclass Table: The Five Core Components of a PA Template
Component Purpose Example Snippet (using Epic .dotphrase syntax) Key Considerations
1. The Header Provides essential, at-a-glance demographic and insurance information. Auto-populates patient-specific data to prevent manual entry errors. Patient: @NAME@ (MRN: @MRN@, DOB: @DOB@)
Payer: @INSURPROVNAME@
Medication: ***
 This section is 100% about automation. Learn the specific “wildcards” or “SmartLinks” for your EHR to pull this data automatically. The `***` is a placeholder for you to manually type the drug name.
2. The Justification Statement A clear, concise opening sentence that immediately states the request and the primary diagnosis. This is a request for prior authorization for the medication listed above for the treatment of @PROB(ACTIVE)@. The `@PROB(ACTIVE)@` SmartLink in Epic is incredibly powerful. It will pull in the patient’s active problem list, allowing you to select the correct diagnosis. The goal is to tie the drug to a specific, coded ICD-10 diagnosis from the very first sentence.
3. Clinical Criteria Checklist The core of the template. It is structured to mirror the payer’s clinical policy questions, acting as your guide for the chart review. Diagnosis Confirmation: Patient diagnosed with Type 2 Diabetes Mellitus on @DIAGNOSISDATE(XXX)@.
Lab Values: Most recent A1c is @LASTLAB(A1C)@ on @LASTLABDATE(A1C)@.		 This is where you build the case. Use clear headings for each criterion (e.g., “Diagnosis,” “Lab Values,” “Treatment History”). Use SmartLinks to pull in dynamic data like the last lab value. This saves time and ensures accuracy.
4. Formulary Failure Sub-Template A structured, repeatable block within the main template used to document each required formulary trial and failure. - Failed Formulary Agent: ***
- Dates of Trial: ***
- Reason for Discontinuation: *** (Documented in note by Dr. @PCPNAME@ on ***).		 This is the most critical part for step-therapy edits. The structure forces you to gather all the necessary data points: the drug, the timeframe, and most importantly, the reason for failure, including a citation of where you found that information in the chart.
5. Closing & Attestation A professional closing statement and placeholders for provider information. Based on the clinical information provided, this medication is medically necessary. Please feel free to contact our office with any questions.

Requesting Provider: @PROVNAME@, NPI: @PROVNPI@		 This provides a clean, professional finish to your note and ensures all necessary provider identifiers are included for the payer.

18.3.3 Building Your Arsenal: A Cross-Platform Guide to Smart Tools

The terminology and specific steps for creating templates vary between EHRs, but the goal is the same. Here, we provide a practical guide to building these tools in the major systems.

Epic: Mastering SmartPhrases (.dotphrases)

Epic’s SmartPhrase functionality is arguably the most powerful and flexible templating tool in any EHR. It allows for simple text expansion, but its true power lies in the use of SmartLinks (to pull data) and SmartLists (to create choices).

Creating Your First SmartPhrase: A Step-by-Step Guide
  1. From the Epic menu, navigate to “Tools” -> “SmartTool Editors” -> “SmartPhrase Manager.”
  2. Click “New” to create a new SmartPhrase.
  3. Name: This is your “.dotphrase” trigger. It must start with a period. Make it intuitive and easy to remember. Good example: .PAJARDIANCE. Bad example: .PA123.
  4. Content: This is where you build your template. You can type plain text, but the magic is in adding SmartTools. While in the editor, you can click the “SmartTools” button to search for available wildcards like `@NAME@`, `@DOB@`, etc.
  5. Wildcards (`***`): The triple asterisk is the standard Epic wildcard for a “fill-in-the-blank” field. When you use the SmartPhrase, you can use the F2 key to jump between these fields.
  6. SmartLists (`{list name:choice 1:choice 2}`): These create dropdown or multiple-choice selections within your note. For example, `{Statin Intolerance:Myalgia:LFT elevation:Other}` lets you pick the specific reason for statin failure.
  7. Save and Share: Save the phrase. You can also add other users as “owners” or “users” to share your templates with your pharmacy team, ensuring everyone is using the same standardized format.

Cerner: Leveraging Autotext and PowerNotes

Cerner’s equivalent to SmartPhrases is typically called “Autotext.” The functionality is similar, allowing you to save blocks of text that can be inserted with a short trigger phrase. Cerner also utilizes “PowerNotes,” which are more structured note templates that can contain Autotext within them.

  • Creating Autotext: This is often done directly within a note. You can type out your desired template text, highlight it, and then use a menu option (often right-click or in the toolbar) called “Create Autotext” or “Save as Autotext.”
  • Tokens/Variables: Cerner uses a different syntax for auto-populating data, often using `@` symbols or other tokens. You will need to learn the specific tokens for your organization’s Cerner build (e.g., `@PAT_NAME@`, `@PAT_DOB@`). This information is usually available from your IT or clinical informatics department.
  • PowerNotes Integration: For PAs, it’s highly effective to work with your informatics team to build a dedicated “Prior Authorization” section into existing PowerNote templates. This section can have fields that your Autotext templates can then populate, creating a highly structured and efficient workflow.

18.3.4 Masterclass Deep Dive: Template Examples by Therapeutic Area

Theory is useful, but practical examples are what build mastery. Below are detailed, ready-to-use template examples for high-volume drug classes. These are written in Epic’s SmartPhrase syntax but the principles can be applied to any EHR.

Template 1: SGLT2 Inhibitor (e.g., Jardiance, Farxiga) for T2DM
.PA_SGLT2

Patient: @NAME@ (MRN: @MRN@, DOB: @DOB@)
Payer: @INSURPROVNAME@
Medication: {SGLT2:Jardiance:Farxiga:Invokana:Steglatro} 10 mg daily

This is a request for prior authorization for the SGLT2 inhibitor listed above for the treatment of Type 2 Diabetes Mellitus (E11.9).

1. Diagnosis Confirmation:
Patient was diagnosed with Type 2 Diabetes Mellitus. Patient's most recent Hemoglobin A1c is @LASTLAB(A1C)@ on @LASTLABDATE(A1C)@.

2. History of Formulary Trial and Failure:
This request meets step-therapy requirements. The patient has had an inadequate response or intolerance to the following formulary agents:

- Metformin:
- Trial Period: ***
- Maximum Tolerated Dose: ***
- Reason for Discontinuation/Inadequate Response: {Metformin Failure:Gastrointestinal intolerance:Renal contraindication (eGFR @LASTLAB(EGFR)@):Lactic acidosis risk:Suboptimal A1c reduction despite max dose}

- {Second Line Agent:DPP-4 Inhibitor (Januvia):Sulfonylurea (Glipizide):Other}
- Trial Period: ***
- Maximum Tolerated Dose: ***
- Reason for Discontinuation/Inadequate Response: *** (As documented in note from *** on ***).

3. Clinical Justification for SGLT2 Inhibitor:
In addition to glycemic control, this agent is specifically indicated for this patient due to {Comorbidity:Established atherosclerotic cardiovascular disease (ASCVD):Chronic kidney disease (CKD):Heart failure (HF)}. This aligns with current ADA/AACE guidelines for comprehensive cardiovascular risk reduction.

Based on the clinical information provided, this medication is medically necessary. Please feel free to contact our office with any questions.

Requesting Provider: @PROVNAME@, NPI: @PROVNPI@
Template 2: TNF Inhibitor (e.g., Humira, Enbrel) for Rheumatoid Arthritis
.PA_TNF_RA

Patient: @NAME@ (MRN: @MRN@, DOB: @DOB@)
Payer: @INSURPROVNAME@
Medication: {TNF Inhibitor:Humira (adalimumab):Enbrel (etanercept):Cimzia (certolizumab pegol)}

This is a request for prior authorization for the TNF inhibitor listed above for the treatment of Rheumatoid Arthritis (M06.9).

1. Diagnosis Confirmation & Severity:
Patient was diagnosed with moderate to severe active Rheumatoid Arthritis by a board-certified Rheumatologist, Dr. ***. The diagnosis is supported by positive RF/ACPA serology and imaging. The most recent disease activity score (DAS28) is *** on ***, indicating high disease activity.

2. Latent TB Screening:
Patient has been screened for latent tuberculosis with a @LASTLAB(TST)@ test on @LASTLABDATE(TST)@ with a result of @LASTLAB(TST)@. Patient has been counseled on the risks of immunosuppression.

3. History of DMARD Trial and Failure:
This request meets step-therapy requirements. The patient has had an inadequate response or intolerance to a conventional Disease-Modifying Antirheumatic Drug (DMARD):

- Methotrexate:
- Trial Period: Patient has completed a trial of at least 3 months from *** to ***.
- Maximum Tolerated Dose: *** mg weekly.
- Reason for Failure/Intolerance: {MTX Failure:Lack of efficacy (persistent synovitis/elevated CRP):Hepatotoxicity (LFT elevation):Gastrointestinal intolerance:Stomatitis:Other} (Documented in rheumatology note on ***).

Based on the failure of conventional DMARD therapy and the patient's high disease activity, initiation of a biologic agent is clinically indicated per American College of Rheumatology (ACR) guidelines.

Requesting Provider: @PROVNAME@, NPI: @PROVNPI@

18.3.5 Best Practices and Avoiding the Pitfalls of Automation

Templates are powerful tools, but like any tool, they can be misused. Effective automation requires a commitment to best practices and an awareness of common pitfalls.

The Cardinal Rule of Templates: Proofread Before You Sign

The greatest danger of templates is “automation bias”—the tendency to trust the automated output without verification. A SmartLink can pull incorrect or outdated information. A SmartList choice might be mis-clicked. A template is a DRAFT, not a final document. You must always perform a final, careful review of the generated note to ensure it is accurate, makes clinical sense, and truly reflects the patient’s specific story before sending it to the provider to sign or submitting it to the payer.

Masterclass Table: Template Best Practices
Best Practice Why It’s Important Actionable Steps
Follow the 80/20 Rule You will waste immense time trying to build a perfect template for a drug you only see once a year. Your efficiency gains come from automating high-volume, repetitive tasks. For one week, keep a log of every PA you work on. At the end of the week, identify the top 5-10 drugs or drug classes that took up the most time. Build your first templates for these.
Create a Shared Team Library Consistency is key. If every pharmacist on your team uses a different format, it leads to variable quality and inefficiency when covering for colleagues. Designate a “template owner” or small committee. Build and validate templates together. Use the “sharing” features in your EHR to create a single, official library of PA templates for the entire pharmacy department.
Cite Your Sources A statement like “patient failed metformin” is weak. A statement like “patient failed metformin due to GI intolerance as documented in Dr. Smith’s note on 5/15/2024” is powerful and credible. Build citation placeholders directly into your templates, especially in the formulary failure sections. Make it a mandatory part of your workflow to include the note author and date for any claims of treatment failure or intolerance.
Schedule Regular Reviews Payer clinical policies are not static. They change. A perfect template from last year may be missing a newly required criterion this year. Set a recurring calendar appointment every quarter or every six months to review your top 10 most-used templates. Compare them against the current PA criteria from your top payers and make any necessary updates.
Balance Structure and Flexibility A template that is too rigid cannot accommodate a patient’s unique clinical nuances. A template that is too flexible is just a blank page. Use structured fields (like SmartLists) for common, predictable criteria. Always include a free-text `***` field for “Additional Clinical Comments” or “Extenuating Circumstances” to allow for customization when needed.