Maximizing Medical Documentation Efficiency with Electronic Templates

1. Critique of the Week Wes Wilkerson February 6, 2006

2. 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

3. 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)

4. Article of Interest Template-guided versus undirected written medical documentation: A prospective, randomized trial in a Family Medicine Residency Clinic. JABFP 2005;18(6):464-9. Mulvehill S, Schneider G, Cullen CM, Roaten S, Foster B, and Porter A

5. Significance of study • The author’s 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.

6. 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.”

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

8. 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?

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

10. 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

11. 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

12. 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; p<0.0001 • 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.

13. 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?

14. 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.

15. Future Studies • Author’s 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

16. 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

17. 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?

18. 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

19. Discussion???

20. Critique of the Week Wes Wilkerson February 6, 2006