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Critique of the Week

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

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Critique of the Week

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  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

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