Critique of the Week

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Critique of the Week

• Wes Wilkerson
• February 6, 2006

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My Interests

• Electronic Medical Record (EMR) impacts
• Improved quality of documentation
• Increased reimbursement
• Decreased patient visit time
• Increased quality of patient care
• My experience
• Template based EMR Centricity
• Increased efficiency and quality of visit
  interaction and documentation
• Subsequent free form documentation seemed more
  thorough than most colleges

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Why this article?

• My interest in EMRs is due to the positive
  experience I gained using templates
• Paper templates have been in use since before EMR
• Studies evaluating paper templates may be
  applicable to evaluation EMR templates
• By applying previously tested methods with design
  improvements, the research may yield useful
  results to a newer concept (EMRs)

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Article of Interest

• Template-guided versus undirected written medical
  documentation A prospective, randomized trial in
  a Family Medicine Residency Clinic. JABFP
  200518(6)464-9.
• Mulvehill S, Schneider G, Cullen CM, Roaten S,
• Foster B, and Porter A

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Significance of study

• The authors of this study had a similar vision
  stating that the movement to an EMR was expected
  yet currently prohibited due to cost.
• They illustrated the link between paper based
  templates and EMR based templates
• They expected templates to improve their practice
  but wanted data to make an informed decision.

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Significance of study (cont)

• Introduction points
• Quality improvement projects, research, and
  legal issues all rely on a complete accurate
  record.
• Coding, billing, and reimbursement depend on
  accurate documentation in specific areas.
• The process of recording a patient visit takes
  time, whereby affecting physician productivity
  and income.
• Recent policies within the American Academy of
  Family Physicians, other medical specialty
  organizations, and from the federal government
  have called for a transition to an electronic
  medical record (EMR).
• Lessons learned evaluating paper documentation
  methods may translate to use on an EMR platform.

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Trial Classification

• Longitudinal (prospective)
• Randomized
• Controlled
• Explanatory
• Objective
• To compare a template-driven medical
  documentation system to undirected handwritten
  documentation

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Hypotheses

• As compared to undirected written documentation,
  does the use of a paper based template
• decrease physician evaluation time?
• increase coding and reimbursement levels?
• improve physician satisfaction with the
  satisfaction with the documentation record?

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Variables

• Independent variable
• Template system vs. Control
• Dependent variables
• Physician evaluation time
• Gross billing
• Physician documentation satisfaction

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Operational Definitions

• Physician evaluation time
• Calculated using the time the patient was placed
  in the room and clinic discharge time
• Billing amount
• An independent trained and certified coder was
  hired to determine the billing amounts for all
  patients visits included in the study based upon
  1995 HCFA guidelines
• Physician satisfaction
• Response to survey produced by the American
  College of Emergency Physicians

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Data collection method

• Chart review by a blinded professional coder
• Team that used template system
• Team that used undirected written documentation
• Questionnaire at the conclusion of the trial
  recorded responses via Likert Scale.
• 10 questions completed by resident physicians
  using template system
• 3 questions completed by faculty physicians
• Questionnaire was an unvalidated opinion survey
  provided by the American College of Emergency
  Physicians

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Results

• There was a statistical significance in mean
  billing amount between the two groups.
• Control Group 149.63
• Template Group 163.38
• t 4.67 df 1235 plt0.0001
• There was no statistical significance in mean
  clinic time between the two groups.
• Physician survey favored continuing to use the
  template documentation system.
• Results were reported as mean response to Likert
  Scale in question 10 for physicians and question
  1 for faculty.

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Limitations

• Total patient visit time included other elements
  than time spent with physician
• What is the relationship between template
  efficiency and training?
• Did they train long enough?
• Had any of the participants ever used templates
  in the past?

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Limitations (cont.)

• Were the visits the same between groups?
• No diagnosis index was generated and compared
• Lost records were assumed to be equal between the
  two groups but blinding made the impossible to
  verify.

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Future Studies

• Authors Mentioned
• Productivity incentives could improve
  satisfaction among users
• Evaluation of net income generated from the
  increased gross billing
• Template use and patient satisfaction
• Template use and the physician patient
  interaction
• Comparison of paper templates to EMR templates

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Future Studies (cont.)

• My Additions
• Control for patient complexity between groups
• ICD-9 codes
• Monitor only time spent during the visit with the
  patient for time difference evaluation
• Cameras
• Blind document quality evaluators
• Control for past template use
• Distribute questionnaire to both groups as
  opposed to just the intervention group

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Future Studies (cont.)

• Cross over study examining user opinions
• Template then free form
• Free form then template
• Opinions
• Improve learning proper documentation due to a
  particular order?
• Change the scores (satisfaction, visit time) due
  to a particular order?
• Did the users believe that it improved their
  colleges documentation quality or visit time?

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Summary

• Study had a good frame work to evaluate billing
• Improvements can be made on evaluating visit time
  and documentation satisfaction and quality
• It partially supported the finding of a similar
  study conducted in an Emergency Department
• It supported the link between paper based
  template evaluation an EMRs

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Discussion???
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Critique of the Week

• Wes Wilkerson
• February 6, 2006