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

BackgroundClinical 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.MethodsDizziness 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.ResultsThe 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.ConclusionsProviders 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.

[1]  O. Guntinas-Lichius.  Acute vestibular syndrome. , 1999, The New England journal of medicine.

[2]  Kurt C Stange,et al.  Features of Medical Records in Community Practices and Their Association With Preventive Service Delivery , 2005, Medical care.

[3]  J. Iglehart.  Health insurers and medical-imaging policy--a work in progress. , 2009, The New England journal of medicine.

[4]  Steven H. Brown,et al.  The Effect of Standardized, Computer-Guided Templates on Quality of VA Disability Exams , 2006, AMIA.

[5]  Clement J. McDonald,et al.  Efficiency, Comprehensiveness and Cost-effectiveness when comparing Dictation and Electronic Templates for Operative Reports , 2005, AMIA.

[6]  D. Zee,et al.  Imprecision in patient reports of dizziness symptom quality: a cross-sectional study conducted in an acute care setting. , 2007, Mayo Clinic proceedings.

[7]  P. Pronovost,et al.  The checklist--a tool for error management and performance improvement. , 2006, Journal of critical care.

[8]  Brady T. West,et al.  Dizziness presentations in U.S. emergency departments, 1995-2004. , 2008, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[9]  Jacqueline A Pugh,et al.  Clinical practice guideline implementation strategy patterns in Veterans Affairs primary care clinics. , 2007, Health services research.

[10]  R. Tusa,et al.  Unnecessary diagnostic tests often obtained for benign paroxysmal positional vertigo. , 2009, Medical science monitor : international medical journal of experimental and clinical research.

[11]  I. Yermilov,et al.  How much do standardized forms improve the documentation of quality of care? , 2007, The Journal of surgical research.

[12]  Brady T. West,et al.  Value of computed tomography scans in ED dizziness visits: analysis from a nationally representative sample. , 2010, The American journal of emergency medicine.

[13]  M. McDermott,et al.  Adequacy of medical chart review to characterize emergency care for asthma: findings from the Illinois Emergency Department Asthma Collaborative. , 2006, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[14]  Hanna A Saadah,et al.  Vertigo , 1920, The Lancet.

[15]  M. Luby,et al.  Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison , 2007, The Lancet.

[16]  D. Gifford,et al.  Do malpractice concerns, payment mechanisms, and attitudes influence test-ordering decisions? , 2004, Neurology.

[17]  C. M. Cullen,et al.  Template-guided versus undirected written medical documentation: a prospective, randomized trial in a family medicine residency clinic. , 2005, The Journal of the American Board of Family Practice.

[18]  J. Kanegaye,et al.  Improved documentation of wound care with a structured encounter form in the pediatric emergency department. , 2005, Ambulatory pediatrics : the official journal of the Ambulatory Pediatric Association.

[19]  K. Marill,et al.  Prospective, randomized trial of template-assisted versus undirected written recording of physician records in the emergency department. , 1999, Annals of emergency medicine.

[20]  J. Wilson,et al.  Evaluation of investigations to diagnose the cause of dizziness in elderly people: a community based controlled study , 1996, BMJ.

[21]  A. Sodickson,et al.  Recurrent CT, cumulative radiation exposure, and associated radiation-induced cancer risks from CT of adults. , 2009, Radiology.

[22]  M. Young,et al.  Health services research , 2008, Journal of General Internal Medicine.

[23]  D. Rubin,et al.  The central role of the propensity score in observational studies for causal effects , 1983 .

[24]  R. Deyo.  Imaging idolatry: the uneasy intersection of patient satisfaction, quality of care, and overuse. , 2009, Archives of internal medicine.

[25]  K C Stange,et al.  How valid are medical records and patient questionnaires for physician profiling and health services research? A comparison with direct observation of patients visits. , 1998, Medical care.

[26]  Jesse C. Crosson,et al.  Diabetes Flow Sheet Use Associated With Guideline Adherence , 2008, The Annals of Family Medicine.