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Appl Clin Inform 2016; 07(03): 790-802
DOI: 10.4338/ACI-2015-11-RA-0164
Research Article
Schattauer GmbH

The Use of Evidence-Based, Problem-Oriented Templates as a Clinical Decision Support in an Inpatient Electronic Health Record System

Raj Mehta
1   University of Florida - Hospital Medicine, Gainesville, Florida, U.S.A.
,
Nila S. Radhakrishnan
1   University of Florida - Hospital Medicine, Gainesville, Florida, U.S.A.
,
Carrie D. Warring
2   University of Florida - Medicine, Gainesville, Florida, U.S.A.
,
Ankur Jain
1   University of Florida - Hospital Medicine, Gainesville, Florida, U.S.A.
,
Jorge Fuentes
2   University of Florida - Medicine, Gainesville, Florida, U.S.A.
,
Angela Dolganiuc
3   University of Florida - Gastroenterology, Hepatology, and Nutrition, Gainesville, Florida, U.S.A.
,
Laura S. Lourdes
4   Indiana University - Hematology/Oncology, Indianapolis, Indiana, U.S.A
,
John Busigin
5   University of Tennessee-Knoxville - Family Medicine, Knoxville, Tennessee, U.S.A.
,
Robert R. Leverence
6   University of Florida - Medicine/Hospital Medicine, Gainesville, Florida, U.S.A
› Author Affiliations

Funding Source This work was supported by the Gatorade Trust through funds distributed by the University of Florida, Department of Medicine.
Further Information

Correspondence to:

Raj Mehta, M.D.
Division of Hospital Medicine
Department of Medicine
University of Florida
P.O. Box 100238
Gainesville
FL 32610
Phone: (352) 594-3589   
Fax: (352) 265-0379   

Publication History

received: 02 March 2016

accepted: 30 May 2016

Publication Date:
19 December 2017 (online)

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Summary

Background

The integration of clinical decision support (CDS) in documentation practices remains limited due to obstacles in provider workflows and design restrictions in electronic health records (EHRs). The use of electronic problem-oriented templates (POTs) as a CDS has been previously discussed but not widely studied.

Objective

We evaluated the voluntary use of evidence-based POTs as a CDS on documentation practices.

Methods

This was a randomized cohort (before and after) study of Hospitalist Attendings in an Academic Medical Center using EPIC EHRs. Primary Outcome measurement was note quality, assessed by the 9-item Physician Documentation Quality Instrument (PDQI-9). Secondary Outcome measurement was physician efficiency, assessed by the total charting time per note.

Results

Use of POTs increased the quality of note documentation [score 37.5 vs. 39.0, P = 0.0020]. The benefits of POTs scaled with use; the greatest improvement in note quality was found in notes using three or more POTs [score 40.2, P = 0.0262]. There was no significant difference in total charting time [30 minutes vs. 27 minutes, P = 0.42].

Conclusion

Use of evidence-based and problem-oriented templates is associated with improved note quality without significant change in total charting time. It can be used as an effective CDS during note documentation.

Citation: Mehta R, Radhakrishnan NS, Warring CD, Jain A, Fuentes J, Dolganiuc A, Lourdes LS, Busigin J, Leverence RR. The use of evidence-based, problemoriented templates as a clinical decision support in an inpatient electronic health record system.


 

Keywords

Clinical information systems - electronic health records and systems - clinical decision support - clinical documentation and communications - encounter notes - inpatient care

 


 

Conflicts of Interest

The authors declare that they have no conflicts of interest in the research.


Correspondence to:

Raj Mehta, M.D.
Division of Hospital Medicine
Department of Medicine
University of Florida
P.O. Box 100238
Gainesville
FL 32610
Phone: (352) 594-3589   
Fax: (352) 265-0379   


  Permissions and Reprints