Prospective, randomized trial of template-assisted versus undirected written recording of physician records in the emergency department

Improving clinical documentation of evaluation and management care and patient acuity improves reimbursement as well as quality metrics

OBJECTIVE

Accurate documentation of patient care and acuity is essential to determine appropriate reimbursement as well as accuracy of key publicly reported quality metrics. We sought to investigate the impact of standardized note templates by inpatient advanced practice providers (APPs) on evaluation and management (E/M) charge capture, including outside of the global surgical package (GSP), and quality metrics including case mix index (CMI) and mortality index (MI). We hypothesized this clinical documentation initiative as well as improved coding of E/M services would result in increased reimbursement and quality metrics.

METHODS

A documentation and coding initiative on the heart and vascular service line was initiated in 2016 with focus on improving inpatient E/M capture by APPs outside the GSP. Comprehensive training sessions and standardized documentation templates were created and implemented in the electronic medical record. Subsequent hospital care E/M (current procedural terminology codes 99231, 99232, 99233) from the years 2015 to 2017 were audited and analyzed for charge capture rates, collections, work relative value units (wRVUs), and billing complexity. Data were compared over time by standardizing CMS values and reimbursement rates. In addition, overall CMI and MI were calculated each year.

RESULTS

One year following the documentation initiative, E/M charges on the vascular surgery service line increased by 78.5% with a corresponding increase in APP charges from 0.4% of billable E/M services to 70.4% when compared with pre-initiative data. The charge capture of E/M services among all inpatients rose from 21.4% to 37.9%. Additionally, reimbursement from CMS increased by 65% as total work relative value units generated from E/M services rose by 78.4% (797 to 1422). The MI decreased over the study period by 25.4%. Additionally, there was a corresponding 5.6% increase in the cohort CMI. Distribution of E/M encounter charges did not vary significantly. Meanwhile, the prevalence of 14 clinical comorbidities in our cohort as well as length of stay (P = .88) remained non-statistically different throughout the study period.

CONCLUSIONS

Accurate clinical documentation of E/M care and ultimately inpatient acuity is critical in determining quality metrics that serve as important measures of overall hospital quality for CMS value-based payments and rankings. A system-based documentation initiative and expanded role of inpatient APPs on vascular surgery teams significantly improved charge capture and reimbursement outside the GSP as well as CMI and MI in a consistently complex patient population.

Template Design and Analysis: Integrating Informatics Solutions to Improve Clinical Documentation

Background

Electronic health record templates have served a variety of functions, such as improving documentation for reliable reporting of health care outcomes. Standardizing template documentation has been important for accurately capturing case workload and supporting quality improvement initiatives.

Methods

North Florida/South Georgia Veterans Health System consists of 2 Florida-based hospitals: Malcom Randall Veterans Affairs Medical Center (MRVAMC) in Gainesville, and Lake City Veterans Affairs Medical Center (LCVAMC). In the first quarter of fiscal year 2017, MRVAMC and LCVAMC had a below-average case severity index (CSI) of 0.76 and 0.81, respectively, compared with that of the 0.96 national average for the Veterans Health Administration (VHA). An innovative history and physical template design with embedded informatics tools was created to improve clinical documentation.

Results

Compliance with standardized history and physical medicine template use was monitored for about 1 year after standardized template implementation. Compliance improved from 43.2% in June 2018 to 89.9% in June 2019 at MRVAMC and increased from 48.2% in June 2018 to 96.9% in June 2019 at LCVAMC. CSI improved to 0.97 at MRVAMC and 1.07 at LCVAMC in the first quarter of fiscal year 2019, which exceeded the VHA national average of 0.89 during the same period.

Conclusions

NF/SGVHS integrated informatics solutions within template design was associated with an increase in CSI via improved clinical documentation.

Strategies for improving physician documentation in the emergency department: a systematic review

BACKGROUND

Physician chart documentation can facilitate patient care decisions, reduce treatment errors, and inform health system planning and resource allocation activities. Although accurate and complete patient chart data supports quality and continuity of patient care, physician documentation often varies in terms of timeliness, legibility, clarity and completeness. While many educational and other approaches have been implemented in hospital settings, the extent to which these interventions can improve the quality of documentation in emergency departments (EDs) is unknown.

METHODS

We conducted a systematic review to assess the effectiveness of approaches to improve ED physician documentation. Peer reviewed electronic databases, grey literature sources, and reference lists of included studies were searched to March 2015. Studies were included if they reported on outcomes associated with interventions designed to enhance the quality of physician documentation.

RESULTS

Nineteen studies were identified that report on the effectiveness of interventions to improve physician documentation in EDs. Interventions included audit/feedback, dictation, education, facilitation, reminders, templates, and multi-interventions. While ten studies found that audit/feedback, dictation, pharmacist facilitation, reminders, templates, and multi-pronged approaches did improve the quality of physician documentation across multiple outcome measures, the remaining nine studies reported mixed results.

CONCLUSIONS

Promising approaches to improving physician documentation in emergency department settings include audit/feedback, reminders, templates, and multi-pronged education interventions. Future research should focus on exploring the impact of implementing these interventions in EDs with and without emergency medical record systems (EMRs), and investigating the potential of emerging technologies, including EMR-based machine-learning, to promote improvements in the quality of ED documentation.

"Minimally invasive research?" Use of the electronic health record to facilitate research in pediatric urology

BACKGROUND

The electronic health record (EHR) was designed as a clinical and administrative tool to improve clinical patient care. Electronic healthcare systems have been successfully adopted across the world through use of government mandates and incentives.

METHODS

Using electronic health record, health information system, electronic medical record, health information systems, research, outcomes, pediatric, surgery, and urology as initial search terms, the literature focusing on clinical documentation data capture and the EHR as a potential resource for research related to clinical outcomes, quality improvement, and comparative effectiveness was reviewed. Relevant articles were supplemented by secondary review of article references as well as seminal articles in the field as identified by the senior author.

FINDINGS

US federal funding agencies, including the Agency for Healthcare Research and Quality, the Patient-Centered Outcomes Research Institute, the National Institutes of Health, and the Food and Drug Administration have recognized the EHR's role supporting research. The main approached to using EHR data include enhanced lists, direct data extraction, structured data entry, and unstructured data entry. The EHR's potential to facilitate research, overcoming cost and time burdens associated with traditional data collection, has not resulted in widespread use of EHR-based research tools.

CONCLUSION

There are strengths and weaknesses for all existing methodologies of using EHR data to support research. Collaboration is needed to identify the method that best suits the institution for incorporation of research-oriented data collection into routine pediatric urologic clinical practice.

Review of implementation strategies to change healthcare provider behaviour in the emergency department

OBJECTIVES

Advances in emergency medicine research can be slow to make their way into clinical care, and implementing a new evidence-based intervention can be challenging in the emergency department. The Canadian Association of Emergency Physicians (CAEP) Knowledge Translation Symposium working group set out to produce recommendations for best practice in the implementation of a new science in Canadian emergency departments.

METHODS

A systematic review of implementation strategies to change health care provider behaviour in the emergency department was conducted simultaneously with a national survey of emergency physician experience. We summarized our findings into a list of draft recommendations that were presented at the national CAEP Conference 2017 and further refined based on feedback through social media strategies.

RESULTS

We produced 10 recommendations for implementing new evidence-based interventions in the emergency department, which cover identifying a practice gap, evaluating the evidence, planning the intervention strategy, monitoring, providing feedback during implementation, and desired qualities of future implementation research.

CONCLUSIONS

We present recommendations to guide future emergency department implementation initiatives. There is a need for robust and well-designed implementation research to guide future emergency department implementation initiatives.

Generating Clinical Notes for Electronic Health Record Systems

Clinical notes summarize interactions that occur between patients and healthcare providers. With adoption of electronic health record (EHR) and computer-based documentation (CBD) systems, there is a growing emphasis on structuring clinical notes to support reusing data for subsequent tasks. However, clinical documentation remains one of the most challenging areas for EHR system development and adoption. The current manuscript describes the Vanderbilt experience with implementing clinical documentation with an EHR system. Based on their experience rolling out an EHR system that supports multiple methods for clinical documentation, the authors recommend that documentation method selection be made on the basis of clinical workflow, note content standards and usability considerations, rather than on a theoretical need for structured data.

Structured Data Entry in the Electronic Medical Record: Perspectives of Pediatric Specialty Physicians and Surgeons

The Epic electronic health record (EHR) platform supports structured data entry systems (SDES), which allow developers, with input from users, to create highly customized patient-record templates in order to maximize data completeness and to standardize structure. There are many potential advantages of using discrete data fields in the EHR to capture data for secondary analysis and epidemiological research, but direct data acquisition from clinicians remains one of the largest obstacles to leveraging the EHR for secondary use. Physician resistance to SDES is multifactorial. A 35-item questionnaire based on Unified Theory of Acceptance and Use of Technology, was used to measure attitudes, facilitation, and potential incentives for adopting SDES for clinical documentation among 25 pediatric specialty physicians and surgeons. Statistical analysis included chi-square for categorical data as well as independent sample t-tests and analysis of variance for continuous variables. Mean scores of the nine constructs demonstrated primarily positive physician attitudes toward SDES, while the surgeons were neutral. Those under 40 were more likely to respond that facilitating conditions for structured entry existed as compared to the two older age groups (p = .02). Pediatric surgeons were significantly less positive than specialty physicians about SDES effects on Performance (p = .01) and the effect of Social Influence (p = .02); but in more agreement that use of forms was voluntary (p = .02). Attitudinal differences likely reflect medical training, clinical practice workflows, and division specific practices. Identified resistance indicate efforts to increase SDES adoption should be discipline-targeted rather than a uniform approach.

A pilot trial of a computerized renal template note to improve resident knowledge and documentation of kidney disease

BACKGROUND

Kidney disease is under-documented in physician notes. The use of template-guided notes may improve physician recognition of kidney disease early in training.

OBJECTIVE

The objective of this study was to determine whether a computerized inpatient renal template note with clinical decision support improves resident knowledge and documentation of kidney disease.

METHODS

In this prospective study, first year medical residents were encouraged to use the renal template note for documentation over a one-month period. The renal template note included an option for classification of acute kidney injury (AKI) and chronic kidney disease (CKD) categories with a link to standard classifications. Pre- and post-knowledge of AKI and CKD categories was tested with a quiz and surveys of resident experience with the intervention were conducted. Appropriate AKI and/or CKD classification was determined in 100 renal template notes and 112 comparable historical internal medicine resident progress notes from approximately one year prior.

RESULTS

2,435 inpatient encounters amongst 15 residents who participated were documented using the renal template note. A significantly higher percent of residents correctly staged earlier stage CKD (CKD3) using the renal template note compared to historical notes (9/46 vs. 0/33, p<0.01). Documentation of AKI and more advanced CKD stages (CKD4 and 5) did not improve. Knowledge based on quiz scores increased modestly but was not significant. The renal template note was well received by residents and was perceived as helping improve knowledge and documentation of kidney disease.

CONCLUSION

The renal template note significantly improved staging of earlier stage CKD (CKD3) with a modest but non-significant improvement in resident knowledge. Given the importance of early recognition and treatment of CKD, future studies should focus on teaching early recognition using template notes with supplemental educational interventions.

4000 clicks: a productivity analysis of electronic medical records in a community hospital ED

OBJECTIVE

We evaluate physician productivity using electronic medical records in a community hospital emergency department.

METHODS

Physician time usage per hour was observed and tabulated in the categories of direct patient contact, data and order entry, interaction with colleagues, and review of test results and old records.

RESULTS

The mean percentage of time spent on data entry was 43% (95% confidence interval, 39%-47%). The mean percentage of time spent in direct contact with patients was 28%. The pooled weighted average time allocations were 44% on data entry, 28% in direct patient care, 12% reviewing test results and records, 13% in discussion with colleagues, and 3% on other activities. Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters. Total mouse clicks approach 4000 during a busy 10-hour shift.

CONCLUSION

Emergency department physicians spend significantly more time entering data into electronic medical records than on any other activity, including direct patient care. Improved efficiency in data entry would allow emergency physicians to devote more time to patient care, thus increasing hospital revenue.

Possibilities and Implications of Using the ICF and Other Vocabulary Standards in Electronic Health Records

There is now widespread recognition of the powerful potential of electronic health record (EHR) systems to improve the health-care delivery system. The benefits of EHRs grow even larger when the health data within their purview are seamlessly shared, aggregated and processed across different providers, settings and institutions. Yet, the plethora of idiosyncratic conventions for identifying the same clinical content in different information systems is a fundamental barrier to fully leveraging the potential of EHRs. Only by adopting vocabulary standards that provide the lingua franca across these local dialects can computers efficiently move, aggregate and use health data for decision support, outcomes management, quality reporting, research and many other purposes. In this regard, the International Classification of Functioning, Disability, and Health (ICF) is an important standard for physiotherapists because it provides a framework and standard language for describing health and health-related states. However, physiotherapists and other health-care professionals capture a wide range of data such as patient histories, clinical findings, tests and measurements, procedures, and so on, for which other vocabulary standards such as Logical Observation Identifiers Names and Codes and Systematized Nomenclature Of Medicine Clinical Terms are crucial for interoperable communication between different electronic systems. In this paper, we describe how the ICF and other internationally accepted vocabulary standards could advance physiotherapy practise and research by enabling data sharing and reuse by EHRs. We highlight how these different vocabulary standards fit together within a comprehensive record system, and how EHRs can make use of them, with a particular focus on enhancing decision-making. By incorporating the ICF and other internationally accepted vocabulary standards into our clinical information systems, physiotherapists will be able to leverage the potent capabilities of EHRs and contribute our unique clinical perspective to other health-care providers within the emerging electronic health information infrastructure.

Use of templates for clinical documentation in psychiatric evaluations-beneficial or counterproductive for residents in training?

In psychiatry, as in other disciplines, electronic templates are replacing handwritten records to meet health care financing regulations and requirements of third-party payers. We address whether these checklists are helpful for residents, especially those beginning training, in learning the foundational skills of their discipline and in recording a comprehensive set of patient data. An informal survey of our residents suggests that residents find the templates useful, though they have advantages and disadvantages. We also review relevant literature from psychiatry and other fields on the use of electronic templates and pose questions about how we might gauge the usefulness of the templates in residents' training and in obtaining valid data for clinical decision-making.

Documentation quality and time costs

The Department of Veterans Affairs (VA) performs over 800,000 disability exams and distributes over $37 billion in disability benefits per year. VA developed and deployed a computer-based disability exam documentation system in order to improve exam report quality and timeliness. We conducted a randomized controlled trial comparing joint disability examinations supported by computerized templates to the examinations documented via dictation, to determine if the system met the intended goals or had unintended consequences. Consenting veterans were randomized to undergo exams documented using computerized templates or via dictation. We compared exam report quality, documentation time costs, encounter length, total time to fulfill an exam request with a finalized exam report, and veteran satisfaction. Computer-based templates resulted in disability exam reports that had higher quality scores (p. 0.042) and were returned to the requesting office faster than exam reports created via dictation (p. 0.02).

Documentation time and veteran satisfaction were similar for both the documentation techniques. Encounter length was significantly longer for the template group. Computer-based templates impacted the VA disability evaluation system by improving report quality scores and production time and lengthening encounter times. Oversight bodies have called for mandated use of computer-based templates nationwide. We believe mandates regarding use of health information technology should be guided by data regarding its positive and negative impacts.

Emergency department documentation templates: variability in template selection and association with physical examination and test ordering in dizziness presentations

Background

Clinical documentation systems, such as templates, have been associated with process utilization. The T-System emergency department (ED) templates are widely used but lacking are analyses of the templates association with processes. This system is also unique because of the many different template options available, and thus the selection of the template may also be important. We aimed to describe the selection of templates in ED dizziness presentations and to investigate the association between items on templates and process utilization.

Methods

Dizziness visits were captured from a population-based study of EDs that use documentation templates. Two relevant process outcomes were assessed: head computerized tomography (CT) scan and nystagmus examination. Multivariable logistic regression was used to estimate the probability of each outcome for patients who did or did not receive a relevant-item template. Propensity scores were also used to adjust for selection effects.

Results

The final cohort was 1,485 visits. Thirty-one different templates were used. Use of a template with a head CT item was associated with an increase in the adjusted probability of head CT utilization from 12.2% (95% CI, 8.9%-16.6%) to 29.3% (95% CI, 26.0%-32.9%). The adjusted probability of documentation of a nystagmus assessment increased from 12.0% (95%CI, 8.8%-16.2%) when a nystagmus-item template was not used to 95.0% (95% CI, 92.8%-96.6%) when a nystagmus-item template was used. The associations remained significant after propensity score adjustments.

Conclusions

Providers use many different templates in dizziness presentations. Important differences exist in the various templates and the template that is used likely impacts process utilization, even though selection may be arbitrary. The optimal design and selection of templates may offer a feasible and effective opportunity to improve care delivery.

Checklists to reduce diagnostic errors

Diagnostic errors are common and can often be traced to physicians' cognitive biases and failed heuristics (mental shortcuts). A great deal is known about how these faulty thinking processes lead to error, but little is known about how to prevent them. Faulty thinking plagues other high-risk, high-reliability professions, such as airline pilots and nuclear plant operators, but these professions have reduced errors by using checklists. Recently, checklists have gained acceptance in medical settings, such as operating rooms and intensive care units. This article extends the checklist concept to diagnosis and describes three types of checklists: (1) a general checklist that prompts physicians to optimize their cognitive approach, (2) a differential diagnosis checklist to help physicians avoid the most common cause of diagnostic error--failure to consider the correct diagnosis as a possibility, and (3) a checklist of common pitfalls and cognitive forcing functions to improve evaluation of selected diseases. These checklists were developed informally and have not been subjected to rigorous evaluation. The purpose of this article is to argue for the further investigation and revision of these initial attempts to apply checklists to the diagnostic process. The basic idea behind checklists is to provide an alternative to reliance on intuition and memory in clinical problem solving. This kind of solution is demanded by the complexity of diagnostic reasoning, which often involves sense-making under conditions of great uncertainty and limited time.

Data from clinical notes: a perspective on the tension between structure and flexible documentation

Clinical documentation is central to patient care. The success of electronic health record system adoption may depend on how well such systems support clinical documentation. A major goal of integrating clinical documentation into electronic heath record systems is to generate reusable data. As a result, there has been an emphasis on deploying computer-based documentation systems that prioritize direct structured documentation. Research has demonstrated that healthcare providers value different factors when writing clinical notes, such as narrative expressivity, amenability to the existing workflow, and usability. The authors explore the tension between expressivity and structured clinical documentation, review methods for obtaining reusable data from clinical notes, and recommend that healthcare providers be able to choose how to document patient care based on workflow and note content needs. When reusable data are needed from notes, providers can use structured documentation or rely on post-hoc text processing to produce structured data, as appropriate.

Critical aspects of emergency department documentation and communication

This article focuses on the unique environment of the emergency department (ED) and the issues that place the provider at increased risk of liability actions. Patient care, quality, and safety should always be the primary focus of ED providers. However, the ED chart is the only lasting record of an ED visit, and attention must be paid to proper and accurate documentation. This article introduces the important aspects of ED documentation and communication, with specific focus on key areas of medico-legal risk, the advantages and disadvantages of the available types of ED medical records, the critical transition points of patient handoffs and changes of shift, and the ideal manner to craft effective discharge and follow-up instructions.

Value of the electronic patient record: an analysis of the literature

We undertook a systematic review of the literature on the basis of published studies on the benefit and costs of Electronic Patient Records (EPRs) to clarify the issue of whether and to what extent the use of an EPR is worthwhile. We carried out a systematic electronic search for articles published between 1966 and early 2004 using MEDLINE, following up cross-references from the articles found. We searched first for suitable medical subject headings (MeSH) for electronic patient record, benefit and costs. We obtained 7860 citations with the MeSH keyword ''Medical Record System, Computerized". After combination with appropriate keywords this number was reduced to 588, after a review by two reviewers independently based on abstracts down to 95, and after a further review based on full-text articles to 19 covering 20 studies. The publications evaluated thus document the economic benefits of EPR in a number of areas, but they do not make a statement of the cost effectiveness of EPR in general.

An electronic health record based on structured narrative

OBJECTIVE

To develop an electronic health record that facilitates rapid capture of detailed narrative observations from clinicians, with partial structuring of narrative information for integration and reuse.

DESIGN

We propose a design in which unstructured text and coded data are fused into a single model called structured narrative. Each major clinical event (e.g., encounter or procedure) is represented as a document that is marked up to identify gross structure (sections, fields, paragraphs, lists) as well as fine structure within sentences (concepts, modifiers, relationships). Marked up items are associated with standardized codes that enable linkage to other events, as well as efficient reuse of information, which can speed up data entry by clinicians. Natural language processing is used to identify fine structure, which can reduce the need for form-based entry.

VALIDATION

The model is validated through an example of use by a clinician, with discussion of relevant aspects of the user interface, data structures and processing rules.

DISCUSSION

The proposed model represents all patient information as documents with standardized gross structure (templates). Clinicians enter their data as free text, which is coded by natural language processing in real time making it immediately usable for other computation, such as alerts or critiques. In addition, the narrative data annotates and augments structured data with temporal relations, severity and degree modifiers, causal connections, clinical explanations and rationale.

CONCLUSION

Structured narrative has potential to facilitate capture of data directly from clinicians by allowing freedom of expression, giving immediate feedback, supporting reuse of clinical information and structuring data for subsequent processing, such as quality assurance and clinical research.

Development and implementation of an oral sign-out skills curriculum

INTRODUCTION

Imperfect sign-out of patient information between providers has been shown to contribute to medical error, but there are no standardized curricula to teach sign-out skills. At our institution, we identified several deficiencies in skills and a lack of any existing training.

AIM

To develop a sign-out curriculum for medical house staff.

SETTING

Internal medicine residency program.

PROGRAM DESCRIPTION

We developed a 1-h curriculum and implemented it in August of 2006 at three hospital sites. Teaching strategies included facilitated discussion, modeling, and observed individual practice with feedback. We emphasized interactive communication, a structured sign-out format summarized by an easy-to-remember mnemonic ("SIGNOUT"), consistent inclusion of key content items such as anticipatory guidance, and use of concrete language.

PROGRAM EVALUATION

We received 34 evaluations. The mean score for the course was 4.44 +/- 0.61 on a 1-5 scale. Perceived usefulness of the structured oral communication format was 4.46 +/- 0.78. Participants rated their comfort with providing oral sign-out significantly higher after the session than before (3.27 +/- 1.0 before vs. 3.94 +/- 0.90 after; p < .001).

DISCUSSION

We developed an oral sign-out curriculum that was brief, structured, and well received by participants. Further study is necessary to determine the long-term impact of the curriculum.

Comparison of data extraction from standardized versus traditional narrative operative reports for database-related research and quality control

BACKGROUND

The purpose of this study was to compare the completeness and reproducibility of data extracted from a standardized operative report (SOR) with the non-standardized operative report (NSOR).

METHODS

Between July and December 2003, operative data were collected from all laparoscopic cholecystectomy procedures performed at the Peter Lougheed Centre Hospital. A standardized format for dictating laparoscopic cholecystectomy operative reports was introduced on October 1, 2003. Non-standardized operative reports dictated in the first 3 months of the study period were compared with SORs dictated in the final 3 months. Two physicians independently extracted data from each operative report into a surgical database.

RESULTS

During the study period, 221 cholecystectomy reports were analyzed (119 SOR and 102 NSOR). Completeness of data extraction for identifying variables (eg, patient name, age, and date of procedure) was similar in the 2 types of reports. However, most other operative and perioperative details were more completely reported in the SOR (95% to 100%) when compared to the NSOR (14% to 100% complete). Furthermore, interobserver agreement between 2 independent data extractors was better for the SOR than the NSOR (0.9972 vs 0.9809, P < .0001).

CONCLUSIONS

Standardized operative reports result in more complete and reliably interpretable operative data compared with NSORs.

Pain assessments and the provision of analgesia: the effects of a templated chart

OBJECTIVES

Many emergency departments (EDs) have incorporated pain assessment scales in the medical record to improve compliance with the requirements of the Joint Commission on Accreditation of Healthcare Organizations. The authors conducted a pre-post trial investigating the effects of introducing a templated chart on the documentation of pain assessments and the provision of analgesia to ED patients.

METHODS

A total of 2,379 charts were reviewed for inclusion based on the presence of a chief complaint related to trauma or nontraumatic pain, with 1,242 charts included in the analysis.

RESULTS

Baseline demographic characteristics, mechanism of injury, location of injury, and initial pain severity were similar in the two groups. The proportion of patients with documentation of pain assessment increased from 41% to 57% (p < 0.001). In particular, traumatic mechanisms and chest, abdominal, and extremity pain yielded the largest improvements in documentation after introduction of the templated charts. Documentation of pain descriptors also improved for time of onset, duration, timing, and context (p < 0.01). Pain control in the templated chart group, however, remained unchanged and the provision of analgesia in the ED was not altered, with the exception of nonsteroidal medications, which decreased from 46% to 36% (p < 0.01).

CONCLUSIONS

Although documentation is improved with a templated chart, this improvement did not translate into improved patient care.

Documentation and coding of ED patient encounters: an evaluation of the accuracy of an electronic medical record

OBJECTIVE

The aim of the study was to describe a paper-based, template-driven and an electronic medical record used for capturing emergency care clinical information and to compare the accuracy of these documentation systems for coding patient encounters using the American Medical Association Current Procedural Terminology-2004 (AMA CPT-2004) evaluation and management codes intended for provider reimbursement.

METHODS

A retrospective, cross-sectional study of 4-consecutive-day samples of ED patient encounter records from 2 similar community hospitals was done. For clinical documentation, hospital A uses an electronic medical record, whereas hospital B uses a paper-based template-driven record. Using a simple analytic model, expert coders A and B, respectively, coded the records from hospitals A and B for completeness. First, power analysis determined the acceptability of the patient record sample sizes (1 - beta = .90 at 1% significance level), and the frequency of AMA CPT-2004 primary evaluation and management codes 99281 through 99285 was calculated. Second, the completeness discrepancy rates for hospitals A and B were compared to determine the accuracy of both the paper-based, template-driven record and the electronic medical record in documenting and representing the clinical encounter. Third, interrater reliability between expert coders A and B was calculated to assess the level of agreement between each expert coder in determining the completeness discrepancy rates between hospitals A and B. Finally, the frequency of primary evaluation and management codes was analyzed to determine if there was a statistically significant difference between the paper-based, template-driven record and the electronic medical record representation of the clinical information, and if that difference could be attributable to the differing clinical documentation systems used in hospitals A and B.

RESULTS

First, descriptive display demonstrated a difference in the frequency of the primary evaluation and management codes 99283 and 99284 within hospital A (expert coder A assessment, 36.1% vs 39.1%; expert coder B assessment, 36.6% vs 38.7%) and hospital B (expert coder A assessment, 47.8% vs 21.9%; expert coder B assessment, 48.6% vs 21.4%) was noted with the median, primary evaluation, and management code for hospital A of 99284 and the median, primary evaluation, and management code for hospital B of 99283. Second, Fisher exact test compared the completeness discrepancy rates between hospitals A and B as assessed by each expert coder and demonstrated no statistically significant difference in the completeness discrepancy rates (accuracy) between the paper-based, template-driven record and the electronic medical record documentation and coding system when assessed by either expert coder A (P = .370) or expert coder B (P = .819). Third, interrater reliability between expert coders A and B was evaluated using Cohen's kappa statistic. When evaluated both individually and jointly with respect to hospitals A and B, expert coders A and B had a good strength of agreement in their assessments of the accuracy of the documentation and coding system for hospital A (kappa = 0.6200) and hospital B (kappa = 0.6906) as well as for both hospitals evaluated together (kappa = 0.6616). Finally, interhospital differences in the frequency of primary evaluation and management codes were evaluated using Pearson chi(2) test with 3 df. The results for expert coder A (chi(2) = 47.4160; P < .001) and expert coder B (chi(2) = 46.5946; P < .001) recognize that there is a statistically significant degree of difference between hospitals A and B in the frequency distribution of primary evaluation and management codes, probably because of the dispersion of codes 99283 and 99284.

CONCLUSIONS

A keystroke-driven, electronic medical record that resides on a knowledge platform that incorporates a clinical structured terminology, administrative coding schemata, AMA CPT-2004 codes and uses object-oriented, open-ended, branching chain clinical algorithms that "force" physician documentation of the clinical elements provides an equally accurate capture and representation of ED clinical encounter data as a paper-based, template-driven documentation system both in terms of the presence or absence of both the medically necessary, discrete data elements and the textual documentation-dependent, medical decision-making elements.

Febrile seizure: measuring adherence to AAP guidelines among community ED physicians

OBJECTIVE

In 1996, the American Academy of Pediatrics published practice parameters for the acute management of febrile seizure. These guidelines emphasize the typically benign nature of the condition and discourage aggressive neurodiagnostic evaluation. The extent to which these suggestions have been adopted by general emergency medicine practitioners is unknown. We sought to describe recent patterns of the emergency department (ED) evaluation of febrile seizures with respect to these parameters.

METHODS

A retrospective review of records of children between 6 month and 6 years of age diagnosed with "febrile seizure" (International Classification of Diseases, Ninth Revision, Clinical Modification 780.31) at 42 community hospital general EDs nationwide was performed. Electronic records of an ED physician billing service from October 2002 to September 2003 were used to identify relevant records. Data had been entered into a proprietary template documentation system, and all charts were reviewed by a professional coder blinded to outcomes of interest. Rates of resource utilization (including lumbar puncture, radiography, hospital admission) were noted.

RESULTS

A total of 1029 charts met inclusion criteria. The overall rate of lumbar puncture was 5.2%, and variations were strongly associated with age (8.4% <18 months old vs 3.3% >18 months old). This low rate and age discrimination were consistent with the guidelines of the American Academy of Pediatrics. Although not recommended in the routine evaluation of febrile seizure, computed tomography was part of the evaluation in 11%. The overall rate of admissions or transfers was 12%.

CONCLUSIONS

Six years after publication of practice parameters, the use of lumbar puncture in the evaluation of febrile seizure is uncommon and most patients are discharged home. However, the relatively frequent use of head computed tomography is inconsistent with these practice guidelines and merits further investigation.

Survey of academic pediatric emergency departments regarding use of evaluation and management codes

OBJECTIVE

The aims of the study were to determine the frequency at which each emergency medicine evaluation and management (E/M) code is used, to identify factors associated with their use by academic pediatric emergency departments (PEDs), and to compare PED E/M code utilization rates with rates reported by Centers for Medicare and Medicaid Services for general emergency departments (EDs).

METHOD

A 24-question survey was sent to 42 academic PED medical directors. Questions pertained to PED demographics, physician staff, records/documentation, billing education, and E/M coding data for 1 year. The general ED E/M code utilization rates were obtained from the published Centers for Medicare and Medicaid Services database. Descriptive statistics and odds ratios were used to report and compare the data.

RESULTS

Twenty (48%) of the surveys were returned, and 9 (21%) completed the E/M coding data questions. From these 9 departments, the mean PED annual census was 46,065 (range, 23,531-92,910). The methods of PED medical record documentation were template (6), handwritten (2), and dictation/transcription (1). Charge documents were completed by the PED physician (3), professional service coders (4), and hospital coders (2). Coding/documentation in-services were provided to the physicians of 7 PEDs, and billing audits were performed in 5 PEDs. The total number of charges for the 9 PEDs was 325,129, 78.4% of the census. Multiple reasons were given for the discrepancy between census and charges. The percentage of each of the 5 levels of service billed was calculated for each of the 9 PEDs. The 2 lowest levels of service were used 38.3% of the time, whereas the 2 highest were used 19.2% of the time. The range for the highest level of service varied widely from 5.3% to 53.3%. Approximately 65% of E/M codes used by general EDs were for the 2 highest levels of service. The PED with the highest percentage of upper level charges (53.4%) was the only PED that used dictation/transcription for documentation.

CONCLUSION

Although the response rate was low, and thus the validity of the results was limited, the findings may serve as a benchmark for E/M code utilization in PEDs. The large variation in use of the E/M codes among the PED in our study and the lower rate of using the highest E/M codes by the PEDs compared with the general EDs suggest potential opportunities for academic PEDs to improve billing practices.

Improved documentation of wound care with a structured encounter form in the pediatric emergency department

OBJECTIVE

Accurate and complete documentation may enhance reimbursement and compliance with financial intermediary regulations, protect against litigation, and improve patient care. We measured the effect of introduction of a structured encounter form on the completeness of documentation of pediatric wound management in a teaching hospital.

METHODS

The Children's Hospital Emergency Department introduced a structured encounter form for use in the documentation of wound care in place of the existing free-text dictation method. Attending physicians and trainees, all unaware of the study, had the option of using the form in place of free-text dictation for patients with lacerations requiring closure. We abstracted 100 consecutive free-text dictations from patients treated before the form's introduction. Following a 3-month run-in period, we abstracted 100 consecutive structured wound records. We compared the 2 chart types for completeness of documentation based on 20 predetermined criteria relevant to pediatric wound care.

RESULTS

Overall completeness of documentation improved with structured forms (80% vs 68% for free text, P < .001), with significant improvements in 6 of 20 individual criteria. Trainees demonstrated improvement in documentation with the structured form, with the greatest improvements among senior-level residents. Documentation of the general physical examination worsened with structured charting.

DISCUSSION

In an academic pediatric emergency department, the use of a structured complaint-specific form improved overall completeness of wound-care documentation. Structured encounter forms may provide for more standardized documentation for a variety of pediatric chief complaints, thereby facilitating communication and ultimately transition to template-driven systems in anticipation of an electronic medical record.

Does the Use of Standardized History and Physical Forms Improve Billable Income and Resident Physician Awareness of Billing Codes?

OBJECTIVES

Resident physician knowledge of financial reimbursement guidelines for patient encounters is limited. We determined whether the use of standardized history and physical examination forms by residents for hospital admissions plus a brief lecture would increase the level of billing codes, increase billable income, and increase resident awareness of billing guidelines.

METHODS

Residents used history and physical examination forms after a brief documentation lecture. Pretrial and posttrial surveys measured awareness of billing guidelines. The admission billing codes for a 6-month period were obtained, and the percentages were compared with a control 6-month period.

RESULTS

There was an absolute increase of 14.5% in the highest code between the two study periods (P < 0.0001). Billable income increased by $10,385. Resident documentation awareness also increased (P < 0.001).

CONCLUSIONS

The use of history and physical examination forms, combined with a brief lecture, significantly increased the percentage of highest billing codes, which increased billable income. Resident awareness of documentation requirements significantly improved.

Experience in implementing inpatient clinical note capture via a provider order entry system

Care providers' adoption of computer-based health-related documentation ("note capture") tools has been limited, even though such tools have the potential to facilitate information gathering and to promote efficiency of clinical charting. The authors have developed and deployed a computerized note-capture tool that has been made available to end users through a care provider order entry (CPOE) system already in wide use at Vanderbilt. Overall note-capture tool usage between January 1, 1999, and December 31, 2001, increased substantially, both in the number of users and in their frequency of use. This case report is provided as an example of how an existing care provider order entry environment can facilitate clinical end-user adoption of a computer-assisted documentation tool-a concept that may seem counterintuitive to some.

Information technology in emergency medicine residency-affiliated emergency departments

OBJECTIVES

To describe acquisition and implementation of information technology (IT) in U.S. emergency medicine (EM) residency-affiliated emergency departments (EDs), including automatic medication error checking.

METHODS

This was a survey of all U.S. EM residencies active in September 2000. Respondents specified whether specific IT tools had been "acquired" and "implemented fully." EDs were categorized according to primary versus affiliated training site, trauma level, and census. Numbers of "yes" responses were compared according to ED type (Kruskal-Wallis test, p < or = 0.05 significant).

RESULTS

Of 121 residency programs, data were obtained from 93 (77%) for a total of 149 EDs. The percentages of EDs that reported full implementation for each technology are as follows: medication error checking, 7%; medication order entry, 18%; nonmedication orders, 7%; clinical documentation, 21%; old electrocardiograms, 62%; laboratory results, 84%; radiography order entry, 62%; image retrieval, 29%; radiologists' interpretations, 67%; cardiology reports, 62%; pathology reports, 70%; surgical reports/dictations, 60%; triage, 34%; tracking, 46%; electronic reference materials, 56%; registration, 84%; accounts, 72%; patient management software package, 20%; voice recognition, 7%. Trauma centers reported more IT tools than nontrauma centers (p = 0.01), and primary training sites reported fewer IT tools than affiliated EDs (p = 0.027).

CONCLUSIONS

Incorporation of IT is not uniform in EDs where EM residents train. Acquisition of effective IT tools varies, and implementation lags behind acquisition. Fully implemented IT for medication error checking was reported in 7% of EDs; an additional 12% had acquired IT without implementing it fully.

Comparison of information obtained by operative note abstraction with that recorded on a standardized data collection form

BACKGROUND

The Ischemic Optic Neuropathy Decompression Trial compared optic nerve decompression surgery with careful follow-up for treatment of patients with nonarteritic ischemic optic neuropathy. Surgeons submitted a standardized data collection form and operative notes for 123 patients randomized to and undergoing surgery. The purpose of this study was to see whether operative notes have sufficient and reliable data to avoid development of a surgery data collection form in future trials.

METHODS

We abstracted data from Ischemic Optic Neuropathy Decompression Trial patient operative notes, calculated the proportion of completed responses, and compared abstracted responses with those originally recorded on corresponding case report forms.

RESULTS

Variables used to identify persons, dates, or eye (left/right) were reported 100% of the time on operative notes and with excellent agreement with those recorded on the case report form (median agreement, 100%; range, 95% to 100%). Categoric variables, used to establish the characteristics of surgical steps, were also reported reliably on operative notes (median agreement, 84%; range, 0 to 100%). Open-ended variables tended to be reported more frequently on operative notes (exact agreement, 57% and 34%, respectively, for complications and postoperative medications). Quantitative variables were infrequently reported but correlated well with values reported on the data collection forms (Pearson correlation coefficients, 0.78, 0.79, 0.94, 0.96). For many variables, disagreements were minor and often were related to interpretation of the operative notes by the abstractor.

CONCLUSION

In our trial, operative note abstraction adequately documented surgery date and surgeon and provided more complete information than the standardized report form with respect to complications but did not provide complete information for other variables.

Child bicyclist injuries: are we obtaining enough information in the emergency department chart?

OBJECTIVE

The purpose of this study was to assess the range of information relevant to bicyclist injury research that is available on routinely completed emergency department medical records.

METHODS

A retrospective chart review of emergency department medical records was conducted on children who were injured as bicyclists and treated at an urban level I pediatric trauma center. A range of variables relevant to bicyclist injury research and prevention was developed and organized according to the Haddon matrix. Routinely completed free text emergency department medical records were assessed for the presence of each of the targeted elements. In addition, medical records of seriously injured patients (for whom a more structured medical record is routinely used) were compared to free form records of less seriously injured patients to identify differences in documentation that may be related to the structure of the medical record.

RESULTS

Information related to previous medical history (96% of records), diagnosis (89%), documentation of pre-hospital care (82%), and child traumatic contact points (81%) were documented in the majority of medical records. Information relevant to prevention efforts was less commonly documented: identification of motor vehicle/object involved in crash (58%), the precipitating event (24%), the location of the crash (23%), and documentation of helmet use (23%). Records of seriously injured patients demonstrated significantly higher documentation rates for pre-hospital care and child traumatic contact points, and significantly lower documentation rates for previous medical history, child kinematics, main body parts impacted, and location of injury event.

CONCLUSIONS

Routinely completed free text emergency department medical records contain limited information that could be used by injury researchers in effective surveillance. In particular information relating to the circumstances of the crash event that might be used to design or target prevention efforts is typically lacking. Routine use of more structured medical records has the potential to improve documentation of key information.

Voice recognition software versus a traditional transcription service for physician charting in the ED

This study was conducted to compare real-time voice recognition software to a traditional transcription service. Two emergency department (ED) physicians dictated 47 charts using a voice dictation software program and a traditional transcription service. Accuracy, word per minute dictation time and turnaround time were calculated from the data. The transcription service used in our study was more accurate than the voice recognition program with an accuracy of 99.7 percent versus 98.5 percent for the voice recognition program. The average number of corrections per chart was 2.5 for the voice recognition program and 1.2 for the traditional transcription service. Turnaround time was much better using the computer voice recognition program with an average turnaround time of 3.65 minutes versus a turnaround time of 39.6 minutes for the traditionally transcribed charts. The charts dictated using the voice recognition program were considerably less costly than the manually transcribed charts. In summary, computer voice recognition is nearly as accurate as traditional transcription, it has a much shorter turnaround time and is less expensive than traditional transcription. We recommend its use as a tool for physician charting in the ED.