The Use of Evidence-Based, Problem-Oriented Templates as a Clinical Decision Support in an Inpatient Electronic Health Record System

A Consensus to Revise the Minimum Speech Test Battery-Version 3

PURPOSE

The Minimum Speech Test Battery (MSTB) for adults was introduced in 1996 (Nilsson et al., 1996) and subsequently updated in 2011 (Advanced-Bionics et al., 2011). The MSTB has been widely used by clinicians as a guide for cochlear implant (CI) candidacy evaluations and to document post-operative speech recognition performance. Due to changes in candidacy over the past 10 years, a revision to the MSTB was needed.

METHOD

In 2022, the Institute for Cochlear Implant Training (ICIT) recruited a panel of expert CI audiologists to update and revise the MSTB. This panel utilized a modified Delphi consensus process to revise the test battery and to improve its applicability considering recent changes in CI care.

RESULTS

This resulted in the MTSB-Version 3 (MSTB-3), which includes test protocols for identifying not only traditional CI candidates but also possible candidates for electric-acoustic stimulation and patients with single-sided deafness and asymmetric hearing loss. The MSTB-3 provides information that supplements the earlier versions of the MSTB, such as recommendations of when to refer patients for a CI, recommended patient-reported outcome measures, considerations regarding the use of cognitive screeners, and sample report templates for clinical documentation of pre- and post-operative care. Electronic versions of test stimuli, along with all the materials described above, will be available to clinicians via the ICIT website.

CONCLUSION

The goal of the MSTB-3 is to be an evidence-based test battery that will facilitate a streamlined standard of care for adult CI candidates and recipients that will be widely used by CI clinicians.

Standardization of Emergency Department Clinical Note Templates: A Retrospective Analysis across an Integrated Health System

BACKGROUND AND OBJECTIVE

 Clinical documentation is essential for conveying medical decision-making, communication between providers and patients, and capturing quality, billing, and regulatory measures during emergency department (ED) visits. Growing evidence suggests the benefits of note template standardization; however, variations in documentation practices are common. The primary objective of this study is to measure the utilization and coding performance of a standardized ED note template implemented across a nine-hospital health system.

METHODS

 This was a retrospective study before and after the implementation of a standardized ED note template. A multi-disciplinary group consensus was built around standardized note elements, provider note workflows within the electronic health record (EHR), and how to incorporate newly required medical decision-making elements. The primary outcomes measured included the proportion of ED visits using standardized note templates, and the distribution of billing codes in the 6 months before and after implementation.

RESULTS

 In the preimplementation period, a total of six legacy ED note templates were being used across nine EDs, with the most used template accounting for approximately 36% of ED visits. Marked variations in documentation elements were noted across six legacy templates. After the implementation, 82% of ED visits system-wide used a single standardized note template. Following implementation, we observed a 1% increase in the proportion of ED visits coded as highest acuity and an unchanged proportion coded as second highest acuity.

CONCLUSION

 We observed a greater than twofold increase in the use of a standardized ED note template across a nine-hospital health system in anticipation of the new 2023 coding guidelines. The development and utilization of a standardized note template format relied heavily on multi-disciplinary stakeholder engagement to inform design that worked for varied documentation practices within the EHR. After the implementation of a standardized note template, we observed better-than-anticipated coding performance.

Use of Epic Electronic Health Record System for Health Care Research: Scoping Review

BACKGROUND

Electronic health records (EHRs) enable health data exchange across interconnected systems from varied settings. Epic is among the 5 leading EHR providers and is the most adopted EHR system across the globe. Despite its global reach, there is a gap in the literature detailing how EHR systems such as Epic have been used for health care research.

OBJECTIVE

The objective of this scoping review is to synthesize the available literature on use cases of the Epic EHR for research in various areas of clinical and health sciences.

METHODS

We used established scoping review methods and searched 9 major information repositories, including databases and gray literature sources. To categorize the research data, we developed detailed criteria for 5 major research domains to present the results.

RESULTS

We present a comprehensive picture of the method types in 5 research domains. A total of 4669 articles were screened by 2 independent reviewers at each stage, while 206 articles were abstracted. Most studies were from the United States, with a sharp increase in volume from the year 2015 onwards. Most articles focused on clinical care, health services research and clinical decision support. Among research designs, most studies used longitudinal designs, followed by interventional studies implemented at single sites in adult populations. Important facilitators and barriers to the use of Epic and EHRs in general were identified. Important lessons to the use of Epic and other EHRs for research purposes were also synthesized.

CONCLUSIONS

The Epic EHR provides a wide variety of functions that are helpful toward research in several domains, including clinical and population health, quality improvement, and the development of clinical decision support tools. As Epic is reported to be the most globally adopted EHR, researchers can take advantage of its various system features, including pooled data, integration of modules and developing decision support tools. Such research opportunities afforded by the system can contribute to improving quality of care, building health system efficiencies, and conducting population-level studies. Although this review is limited to the Epic EHR system, the larger lessons are generalizable to other EHRs.

Your note, your way: how to write an inpatient progress note accurately and efficiently as an intern

A physician's progress note is an essential piece of documentation regarding key events and the daily status of patients during their hospital stay. It serves not only as a communication tool between care team members, but also chronicles clinical status and pertinent updates to their medical care. Despite the importance of these documents, little literature exists on how to help residents to improve the quality of their daily progress notes. A narrative literature review of English language literature was performed and summated to provide recommendations on how to write an inpatient progress note more accurately and efficiently. In addition, the authors will also introduce a method to build a personal template with the goal of extracting relevant data automatically to reduce clicks for an inpatient progress note in the electronic medical record system.

Identification of Key Elements in Prostate Cancer for Ontology Building via a Multidisciplinary Consensus Agreement

BACKGROUND

Clinical data collection related to prostate cancer (PCa) care is often unstructured or heterogeneous among providers, resulting in a high risk for ambiguity in its meaning when sharing or analyzing data. Ontologies, which are shareable formal (i.e., computable) representations of knowledge, can address these challenges by enabling machine-readable semantic interoperability. The purpose of this study was to identify PCa-specific key data elements (KDEs) for standardization in clinic and research.

METHODS

A modified Delphi method using iterative online surveys was performed to report a consensus agreement on KDEs by a multidisciplinary panel of 39 PCa specialists. Data elements were divided into three themes in PCa and included (1) treatment-related toxicities (TRT), (2) patient-reported outcome measures (PROM), and (3) disease control metrics (DCM).

RESULTS

The panel reached consensus on a thirty-item, two-tiered list of KDEs focusing mainly on urinary and rectal symptoms. The Expanded Prostate Cancer Index Composite (EPIC-26) questionnaire was considered most robust for PROM multi-domain monitoring, and granular KDEs were defined for DCM.

CONCLUSIONS

This expert consensus on PCa-specific KDEs has served as a foundation for a professional society-endorsed, publicly available operational ontology developed by the American Association of Physicists in Medicine (AAPM) Big Data Sub Committee (BDSC).

The Effect of Implementation of Guideline Order Bundles Into a General Admission Order Set on Clinical Practice Guideline Adoption: Quasi-Experimental Study

BACKGROUND

Clinical practice guidelines (CPGs) and associated order sets can help standardize patient care and lead to higher-value patient care. However, difficult access and poor usability of these order sets can result in lower use rates and reduce the CPGs' impact on clinical outcomes. At our institution, we identified multiple CPGs for general pediatrics admissions where the appropriate order set was used in <50% of eligible encounters, leading to decreased adoption of CPG recommendations.

OBJECTIVE

We aimed to determine how integrating disease-specific order groups into a common general admission order set influences adoption of CPG-specific order bundles for patients meeting CPG inclusion criteria admitted to the general pediatrics service.

METHODS

We integrated order bundles for asthma, heavy menstrual bleeding, musculoskeletal infection, migraine, and pneumonia into a common general pediatrics order set. We compared pre- and postimplementation order bundle use rates for eligible encounters at both an intervention and nonintervention site for integrated CPGs. We also assessed order bundle adoption for nonintegrated CPGs, including bronchiolitis, acute gastroenteritis, and croup. In a post hoc analysis of encounters without order bundle use, we compared the pre- and postintervention frequency of diagnostic uncertainty at the time of admission.

RESULTS

CPG order bundle use rates for incorporated CPGs increased by +9.8% (from 629/856, 73.5% to 405/486, 83.3%) at the intervention site and by +5.1% (896/1351, 66.3% to 509/713, 71.4%) at the nonintervention site. Order bundle adoption for nonintegrated CPGs decreased from 84% (536/638) to 68.5% (148/216), driven primarily by decreases in bronchiolitis order bundle adoption in the setting of the COVID-19 pandemic. Diagnostic uncertainty was more common in admissions without CPG order bundle use after implementation (28/227, 12.3% vs 19/81, 23.4%).

CONCLUSIONS

The integration of CPG-specific order bundles into a general admission order set improved overall CPG adoption. However, integrating only some CPGs may reduce adoption of order bundles for excluded CPGs. Diagnostic uncertainty at the time of admission is likely an underrecognized barrier to guideline adherence that is not addressed by an integrated admission order set.

Implementation of a Biopsychosocial History and Physical Exam Template in the Electronic Health Record: Mixed Methods Study

BACKGROUND

Patients' perspectives and social contexts are critical for prevention of hospital readmissions; however, neither is routinely assessed using the traditional history and physical (H&P) examination nor commonly documented in the electronic health record (EHR). The H&P 360 is a revised H&P template that integrates routine assessment of patient perspectives and goals, mental health, and an expanded social history (behavioral health, social support, living environment and resources, function). Although the H&P 360 has shown promise in increasing psychosocial documentation in focused teaching contexts, its uptake and impact in routine clinical settings are unknown.

OBJECTIVE

The aim of this study was to assess the feasibility, acceptability, and impact on care planning of implementing an inpatient H&P 360 template in the EHR for use by fourth-year medical students.

METHODS

A mixed methods study design was used. Fourth-year medical students on internal medicine subinternship (subI) services were given a brief training on the H&P 360 and access to EHR-based H&P 360 templates. Students not working in the intensive care unit (ICU) were asked to use the templates at least once per call cycle, whereas use by ICU students was elective. An EHR query was used to identify all H&P 360 and traditional H&P admission notes authored by non-ICU students at University of Chicago (UC) Medicine. Of these notes, all H&P 360 notes and a sample of traditional H&P notes were reviewed by two researchers for the presence of H&P 360 domains and impact on patient care. A postcourse survey was administered to query all students for their perspectives on the H&P 360.

RESULTS

Of the 13 non-ICU subIs at UC Medicine, 6 (46%) used the H&P 360 templates at least once, which accounted for 14%-92% of their authored admission notes (median 56%). Content analysis was performed with 45 H&P 360 notes and 54 traditional H&P notes. Psychosocial documentation across all H&P 360 domains (patient perspectives and goals, mental health, expanded social history elements) was more common in H&P 360 compared with traditional notes. Related to impact on patient care, H&P 360 notes more commonly identified needs (20% H&P 360; 9% H&P) and described interdisciplinary coordination (78% H&P 360; 41% H&P). Of the 11 subIs completing surveys, the vast majority (n=10, 91%) felt the H&P 360 helped them understand patient goals and improved the patient-provider relationship. Most students (n=8, 73%) felt the H&P 360 took an appropriate amount of time.

CONCLUSIONS

Students who applied the H&P 360 using templated notes in the EHR found it feasible and helpful. These students wrote notes reflecting enhanced assessment of goals and perspectives for patient-engaged care and contextual factors important to preventing rehospitalization. Reasons some students did not use the templated H&P 360 should be examined in future studies. Uptake may be enhanced through earlier and repeated exposure and greater engagement by residents and attendings. Larger-scale implementation studies can help further elucidate the complexities of implementing nonbiomedical information within EHRs.

Problem-oriented documentation: design and widespread adoption of a novel toolkit in a commercial electronic health record

Background

Problem-oriented documentation is an accepted method of note construction which facilitates clinical thought processes. However, problem-oriented documentation is challenging to put into practice using commercially available electronic health record (EHR) systems.

Objective

Our goal was to create, iterate, and distribute a problem-oriented documentation toolkit within a commercial EHR that maximally supported clinicians' thinking, was intuitive to use, and produced clear documentation.

Materials and Methods

We used an iterative design process that stressed visual simplicity, data integration, a predictable interface, data reuse, and clinician efficiency. Creation of the problem-oriented documentation toolkit required the use of EHR-provided tools and custom programming.

Results

We developed a problem-oriented documentation interface with a 3-column view showing (1) a list of visit diagnoses, (2) the current overview and assessment and plan for a selected diagnosis, and (3) a list of medications, labs, data, and orders relevant to that diagnosis. We also created a series of macros to bring information collected through the interface into clinicians' notes. This toolkit was put into a live environment in February 2019. Over the first 9 months, the custom problem-oriented documentation toolkit was used in a total of 8385 discrete visits by 28 clinicians in 13 ambulatory departments. After 9 months, the go-live education and EHR optimization teams in our health system began promoting the toolkit to new and existing users of our EHR resulting in a significantly increased uptake by outpatient clinicians. In April 2022 alone, the toolkit was used in more than 92 000 ambulatory visits by 894 users in 271 departments across our health system.

Conclusions

As a health-system client of a commercial EHR, we developed and deployed a revised problem-oriented documentation toolkit that is used by clinicians more than 92 000 times a month. Key success elements include an emphasis on usability and an effective training effort.

Using Electronic Health Record Tools to Decrease Antibiotic Exposure in Infant Sepsis Evaluation

BACKGROUND

Our internal infant sepsis evaluation clinical practice guideline recommends infants with negative culture results who are undergoing sepsis evaluation receive antibiotics until culture results are negative for a maximum of 36 hours. The aims of our project were to decrease the percentage of patients who received >30 hours of administered antibiotic doses (recognizing effective concentrations last until hour 36) and increase 36-hour phrase documentation by using clinical decision support tools.

METHODS

We used quality improvement methodology to study infants aged ≤60 days with negative culture results. The outcome measures were the percentage of patients who received >30 hours of administered antibiotic doses, the percentage of history and physical (H&P) notes that included a statement of the anticipated 36-hour antibiotic discontinuation time (36-hour phrase), and length of stay. The process measure was the use of an illness-specific H&P template or an influencer smartphrase. Balancing measures were readmissions for positive culture results. Interventions included education, an illness-specific H&P template, a criteria-based rule to default to this H&P template, and editing influencer smartphrases.

RESULTS

Over 33 months, 311 patients were included. Percentage of patients who received >30 hours of administered antibiotic doses decreased from 75.6% to 62%. Percentage of H&P notes documenting the 36-hour phrase increased from 4.9% to 75.6%. Illness-specific H&P template and influencer smartphrase usage increased to a mean of 51.5%; length of stay did not change. No readmissions for positive culture results were reported.

CONCLUSIONS

Clinical decision support techniques and educational interventions popularized the "36-hour phrase" and were associated with a reduction in the antibiotic exposure in infants with negative culture results hospitalized for sepsis evaluation.

Factors affecting the manual linking of clinical progress notes to problems in daily clinical practice: A retrospective quantitative analysis and cross sectional survey

This cross sectional study examines how patient characteristics, doctor characteristics, and doctors' education and attitudes affect the extent to which doctors link progress notes to clinical problems. The independent effects of patient characteristics on the linking of notes was examined with a mixed model logistic regression. The effects of doctor characteristics and doctors' education and attitudes on the link ratio was analyzed with univariate analysis of variance. A survey was used to obtain arguments and attitudes on linking notes. For "patient characteristics", the odds of linking increased with an increase in the number of problems or hospital days, decreased, with an increase in the number of involved doctors, medical specialties or the number of notes. For "doctor characteristics", the link ratio increased with more work experience. For "doctors' education and attitudes", the link ratio increased with more familiarity in linking notes and belief in the added value of problem oriented charting. "Overview" was the most cited reason for linking; "I don't know how" the most cited reason for not linking. There is a huge variation within and between all disciplines. Important arguments, for and against, are found. Recommendations for policymakers and medical leadership are given to maximize the benefits.

Documentation of Sleep Hygiene With Melatonin Use in Management of Sleep Disturbance in Children With Neurodevelopmental Disorders: A Quality Improvement Project

INTRODUCTION

The purpose of this quality improvement project was to improve health-care provider consistency in addressing and documenting the use of sleep hygiene in children with neurodevelopmental disorders in alignment with evidence-based strategies.

METHOD

The project took place over 12 weeks and used a parent-completed screening tool and SmartPhrase technology incorporated into the patient note and discharge summary. A preimplementation and postimplementation query of the electronic medical record was used to determine change effectiveness.

RESULTS

The postimplementation query found a 42% increase in documentation of sleep hygiene. In addition, a 55% increase in documentation of sleep hygiene with the initiation of melatonin was noted.

DISCUSSION

The increase in documentation supports success of this initial practice change and demonstrates adherence to evidence-based sleep hygiene strategies. The project provided evidence of a significant improvement in electronic medical record documentation, highlighting an increased awareness of sleep issues in children with neurodevelopmental disorders.

Evaluation of interventions to improve inpatient hospital documentation within electronic health records: a systematic review

OBJECTIVE

Despite the widespread and increasing use of electronic health records (EHRs), the quality of EHRs is problematic. Efforts have been made to address reasons for poor EHR documentation quality. Previous systematic reviews have assessed intervention effectiveness within the outpatient setting or paper documentation. The purpose of this systematic review was to assess the effectiveness of interventions seeking to improve EHR documentation within an inpatient setting.

MATERIALS AND METHODS

A search strategy was developed based on elaborated inclusion/exclusion criteria. Four databases, gray literature, and reference lists were searched. A REDCap data capture form was used for data extraction, and study quality was assessed using a customized tool. Data were analyzed and synthesized in a narrative, semiquantitative manner.

RESULTS

Twenty-four studies were included in this systematic review. Owing to high heterogeneity, quantitative comparison was not possible. However, statistically significant results in interventions and affected outcomes were analyzed and discussed. Education and implementation of a new EHR reporting system were the most successful interventions, as evidenced by significantly improved EHR documentation.

DISCUSSION

Heterogeneity of interventions, outcomes, document type, EHR user, and other variables led to difficulty in measuring EHR documentation quality and effectiveness of interventions. However, the use of education as a primary intervention aligned closely with existing literature in similar fields.

CONCLUSIONS

Interventions implemented to enhance EHR documentation are highly variable and require standardization. Emphasis should be placed on this novel area of research to improve communication between healthcare providers and facilitate data sharing between centers and countries.

PROSPERO Registration Number: CRD42017083494.

Estimating Aspirin Overuse for Primary Prevention of Atherosclerotic Cardiovascular Disease (from a Nationwide Healthcare System)

The American College of Cardiology and American Heart Association recently published guidelines narrowing the indications for low-dose aspirin use. The suitability of the electronic health record (EHR) to identify patients for low-dose aspirin deprescribing is unknown. To apply the 3 low-dose aspirin guidelines to EHR data, the guidelines were deconstructed into components from their narrative text and assigned computer-interpretable definitions based on electronic data interchange standards. These definitions were used to search EHR data to identify patients for aspirin deprescribing. To verify EHR records for low-dose aspirin, we then compared the records with a survey of patients' self-reported use of low-dose aspirin. Of the 3 aspirin guidelines, only 1 had a definition suitable for EHR implementation. The other 2 contained difficult-to-implement phrases (e.g., "higher ASCVD risk", "increased bleeding risk"). An EHR search with the single implementable guideline identified 86,555 people for possible aspirin deprescribing (2% of 5,598,604). Only 676 of 1,135 (60%) patients who self-reported taking low-dose aspirin had an active EHR record for low-dose aspirin at that time. Limitations exist when using EHR data to identify patients for possible low-dose aspirin deprescribing such as incomplete EHR capture of and the interpretation of non-specific terminology when translating guidelines into an electronic equivalent. In conclusion, data show many people unnecessarily take low-dose aspirin.

The development and implementation of a postfall template to improve the content of provider documentation related to falls in the hospital setting

Patient falls are the focus of many hospital prevention and continuous improvement initiatives. This is due to the potential negative impact on patient quality and safety outcomes, cost of care, and litigation risk. The published literature includes an abundance of information regarding fall-prevention programs; however, there is a gap in the knowledge base pertaining to implications of what is documented by providers (physicians, nurse practitioners, physician assistants). There is concern that inadequate documentation may be associated with patient safety and quality issues. These include potential delays in the identification and treatment of fall-related injuries and increased legal risk. A routine analysis of submissions to the hospital's Safety Event Reporting System identified inconsistencies in provider postfall documentation. Because of the potential impact on patient care, safety, financial, and medical-legal implications, a project team was created to optimize the workflow and improve provider documentation as part of the comprehensive postfall program. This article describes the process of creating and implementing a postfall template to standardize and improve the content of postfall notes. The standardized template aligns with the organization's current initiatives to increase caregiver awareness of the impact of patient falls, and to improve patient safety and quality of care.

A qualitative evaluation of clinically coded data quality from health information manager perspectives

BACKGROUND

It is essential that clinical documentation and clinical coding be of high quality for the production of healthcare data.

OBJECTIVE

This study assessed qualitatively the strengths and barriers regarding clinical coding quality from the perspective of health information managers.

METHOD

Ten health information managers and clinical coding quality coordinators who oversee clinical coders (CCs) were identified and recruited from nine provinces across Canada. Semi-structured interviews were conducted, which included questions on data quality, costs of clinical coding, education for health information management, suggestions for quality improvement and barriers to quality improvement. Interviews were recorded, transcribed and analysed using directed content analysis and informed by institutional ethnography.

RESULTS

Common barriers to clinical coding quality included incomplete and unorganised chart documentation, and lack of communication with physicians for clarification. Further, clinical coding quality suffered as a result of limited resources (e.g. staffing and budget) being available to health information management departments. Managers unanimously reported that clinical coding quality improvements can be made by (i) offering interactive training programmes to CCs and (ii) streamlining sources of information from charts.

CONCLUSION

Although clinical coding quality is generally regarded as high across Canada, clinical coding managers perceived quality to be limited by incomplete and inconsistent chart documentation, and increasing expectations for data collection without equal resources allocated to clinical coding professionals.

IMPLICATIONS

This study presents novel evidence for clinical coding quality improvement across Canada.

Electronic medical record implementation for a healthcare system caring for homeless people

Objective

Electronic medical record (EMR) implementation at centers caring for homeless people is constrained by limited resources and the increased disease burden of the patient population. Few informatics articles address this issue. This report describes Boston Health Care for the Homeless Program’s migration to new EMR software without loss of unique care elements and processes.

Materials and methods

Workflows for clinical and operational functions were analyzed and modeled, focusing particularly on resource constraints and comorbidities. Workflows were optimized, standardized, and validated before go-live by user groups who provided design input. Software tools were configured to support optimized workflows. Customization was minimal. Training used the optimized configuration in a live training environment allowing users to learn and use the software before go-live.

Results

Implementation was rapidly accomplished over 6 months. Productivity was reduced at most minimally over the initial 3 months. During the first full year, quality indicator levels were maintained. Keys to success were completing before go-live workflow analysis, workflow mapping, building of documentation templates, creation of screen shot guides, role-based phased training, and standardization of processes. Change management strategies were valuable. The early availability of a configured training environment was essential. With this methodology, the software tools were chosen and workflows optimized that addressed the challenges unique to caring for homeless people.

Conclusions

Successful implementation of an EMR to care for homeless people was achieved through detailed workflow analysis, optimizing and standardizing workflows, configuring software, and initiating training all well before go-live. This approach was particularly suitable for a homeless population.

Use of electronic medical record templates improves quality of care for patients with infantile spasms

BACKGROUND

Infantile spasms (IS) is a neurologic disorder of childhood where time to treatment may affect long-term outcomes. Due to the clinical complexity of IS, care can be delayed.

OBJECTIVE

To determine if the use of electronic medical record templates (EMRTs) improved care quality in patients treated for IS.

METHOD

Records of patients newly diagnosed with IS were retrospectively reviewed both before and after creation of an EMRT for the workup and treatment of IS. Quality of care measures reviewed included delays in treatment plan, medication administration, obtaining neurodiagnostic studies and discharge. The need for repeat neurodiagnostic studies was also assessed. Resident physicians were surveyed regarding template ease of use and functionality.

RESULTS

Of 17 patients with IS, 7 received template-based care and 10 did not. Patients in the non-template group had more delays in treatment (p = 0.010), delay in medication administration (p = 0.10), delay in diagnostic studies (p = 0.01) and delay in discharge (p = 0.39). Neurodiagnostic studies needed to be repeated in 5 out of 10 patients in the non-template group and none of the 7 patients in the template group (p = 0.04). Surveyed resident physicians reported improved coordination in care, avoidance of delays in discharge and improved ability to predict side effects of treatment with template use.

CONCLUSION

In a single centre, the use of protocolised EMRTs decreased treatment delays and the need for repeated invasive procedures in patients with newly diagnosed IS and was reported as easy to use by resident physicians.

IMPLICATIONS

The use of protocolised EMRTs may improve the quality of patient care in IS and other rare diseases.

Transfers from intensive care unit to hospital ward: a multicentre textual analysis of physician progress notes

BACKGROUND

Little is known about documentation during transitions of patient care between clinical specialties. Therefore, we examined the focus, structure and purpose of physician progress notes for patients transferred from the intensive care unit (ICU) to hospital ward to identify opportunities to improve communication breaks.

METHODS

This was a prospective cohort study in ten Canadian hospitals. We analyzed physician progress notes for consenting adult patients transferred from a medical-surgical ICU to hospital ward. The number, length, legibility and content of notes was counted and compared across care settings using mixed-effects linear regression models accounting for clustering within hospitals. Qualitative content analyses were conducted on a stratified random sample of 32 patients.

RESULTS

A total of 447 patient medical records that included 7052 progress notes (mean 2.1 notes/patient/day 95% CI 1.9-2.3) were analyzed. Notes written by the ICU team were significantly longer than notes written by the ward team (mean lines of text 21 vs. 15, p < 0.001). There was a discrepancy between documentation of patient issues in the last ICU and first ward notes; mean agreement of patient issues was 42% [95% CI 31-53%]. Qualitative analyses identified eight themes related to focus (central point - e.g., problem list), structure (organization, - e.g., note-taking style), and purpose (intention - e.g., documentation of patient course) of the notes that varied across clinical specialties and physician seniority.

CONCLUSIONS

Important gaps and variations in written documentation during transitions of patient care between ICU and hospital ward physicians are common, and include discrepancies in documentation of patient information.

Problem-oriented charting: A review

Problem-oriented charting is form of medical documentation that organizes patient data by a diagnosis or problem. In this review, we discuss the history and current use of problem-oriented charting by critically evaluating the literature on the topic. We provide insights with regard to our own institutional use of problem-oriented charting and potential opportunities for research.

The effects of on-screen, point of care computer reminders on processes and outcomes of care

BACKGROUND

The opportunity to improve care by delivering decision support to clinicians at the point of care represents one of the main incentives for implementing sophisticated clinical information systems. Previous reviews of computer reminder and decision support systems have reported mixed effects, possibly because they did not distinguish point of care computer reminders from e-mail alerts, computer-generated paper reminders, and other modes of delivering 'computer reminders'.

OBJECTIVES

To evaluate the effects on processes and outcomes of care attributable to on-screen computer reminders delivered to clinicians at the point of care.

SEARCH STRATEGY

We searched the Cochrane EPOC Group Trials register, MEDLINE, EMBASE and CINAHL and CENTRAL to July 2008, and scanned bibliographies from key articles.

SELECTION CRITERIA

Studies of a reminder delivered via a computer system routinely used by clinicians, with a randomised or quasi-randomised design and reporting at least one outcome involving a clinical endpoint or adherence to a recommended process of care.

DATA COLLECTION AND ANALYSIS

Two authors independently screened studies for eligibility and abstracted data. For each study, we calculated the median improvement in adherence to target processes of care and also identified the outcome with the largest such improvement. We then calculated the median absolute improvement in process adherence across all studies using both the median outcome from each study and the best outcome.

MAIN RESULTS

Twenty-eight studies (reporting a total of thirty-two comparisons) were included. Computer reminders achieved a median improvement in process adherence of 4.2% (interquartile range (IQR): 0.8% to 18.8%) across all reported process outcomes, 3.3% (IQR: 0.5% to 10.6%) for medication ordering, 3.8% (IQR: 0.5% to 6.6%) for vaccinations, and 3.8% (IQR: 0.4% to 16.3%) for test ordering. In a sensitivity analysis using the best outcome from each study, the median improvement was 5.6% (IQR: 2.0% to 19.2%) across all process measures and 6.2% (IQR: 3.0% to 28.0%) across measures of medication ordering. In the eight comparisons that reported dichotomous clinical endpoints, intervention patients experienced a median absolute improvement of 2.5% (IQR: 1.3% to 4.2%). Blood pressure was the most commonly reported clinical endpoint, with intervention patients experiencing a median reduction in their systolic blood pressure of 1.0 mmHg (IQR: 2.3 mmHg reduction to 2.0 mmHg increase).

AUTHORS' CONCLUSIONS

Point of care computer reminders generally achieve small to modest improvements in provider behaviour. A minority of interventions showed larger effects, but no specific reminder or contextual features were significantly associated with effect magnitude. Further research must identify design features and contextual factors consistently associated with larger improvements in provider behaviour if computer reminders are to succeed on more than a trial and error basis.