Problem Specific Templates for Electronic Hospital Documentation

Completed

Conditions: Quality/Accuracy of Physician Documentation
Efficiency of Physician Documentation

Brief Summary: The emergence of electronic documentation has led to multiple new challenges for physicians. Despite positive expectations, many physicians have received electronic health systems with mixed results. Review of current literature has identified the following reasons for concern: increased time required for documentation, deteriorating quality of notes, mindless use of copy-and-paste functions, and fragmentation of clinical work from poorly designed computing workflows. The study of template use has not been done in a large scale or with clear outcome measurements. The purpose of this study is to examine the effects of Problem Specific Templates on quality, accuracy, and efficiency of physician documentation practices.

Detailed Description: This is a prospective cohort study, which will examine the effects of Problem Specific Templates on quality, accuracy, and efficiency of physician documentation practices. The Hospitalist physicians will be the subjects. All physicians of the Hospital Medicine Service will be invited to participate. For the intervention, participating Hospitalists will be trained on the use of templates for 20 common hospital problems. Once trained, the Hospitalists will be asked to use these templates for a one-month period. Pre-intervention and post-intervention medical records will be compared using chart reviews, validated document assessment instruments, physician surveys, and electronic medical record time auditing.

Recruitment & Eligibility

Inclusion Criteria

Physicians: All physicians of the Hospital Medicine Service will be invited to participate

Exclusion Criteria

Arm && Interventions

Group	Intervention	Description
Hospitalists	Hospitalists	Introduction of Problem Specific Templates

Primary Outcome Measures

Name	Time	Method
Quality and Accuracy of Physician Documentation Practices (as measured through chart review)	1 year
Efficiency of Physician Documentation Practices (as measured through the electronic medical record auditing function)	1 year

Secondary Outcome Measures

Name	Time	Method
Physician Assessment of Note-Documenting and Electronic Medical Record (as measured through Physician Questionnaire)	1 year
Frequency of Physician Use of Problem Specific Templates (as measured through chart review)	1 year

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