Structured Clinical Documentation to Improve Quality and Support Practice‐Based Research in Headache

Abstract

Objective To use the electronic medical record (EMR) to optimize patient care, facilitate documentation, and support quality improvement and practice‐based research, in a headache specialty clinic. Background Many physicians enter data into the EMR as unstructured free text and not as discrete data. This makes it challenging to use data for quality improvement or research initiatives. Methods We describe the process of building a customized structured clinical documentation support toolkit, specific for patients seen in a headache specialty clinic. The content was developed through frequent physician meetings to reach consensus on elements that define clinical Best Practices. Tasks were assigned to the care team and data mapped to the progress note. Results The toolkit collects hundreds of fields of discrete, standardized data. Auto scored and interpreted score tests include the Generalized Anxiety Disorder 7‐item, Center for Epidemiology Studies Depression Scale, Migraine Disability Assessment questionnaire, Insomnia Sleep Index, and Migraine‐Specific Quality of Life. We have developed Best Practice Advisories (BPA) and other clinical documentation support tools that alert physicians, when appropriate. As of April 1, 2018, we have used the toolkits at 4346 initial patient visits. We provide screenshots of our toolkits, details of data fields collected, and diagnoses of patients at the initial visit. Conclusions The EMR can be used to effectively structure and standardize headache clinic visits for quality improvement and practice‐based research. We are sharing our proprietary toolkit with other clinics as part of the Neurology Practice‐Based Research Network. These tools are also facilitating clinical research enrollment and a pragmatic trial of comparative effectiveness at the point‐of‐care among migraine patients.

Documentation of International Classification of Headache Disorders Criteria in Patient Medical Records: A Retrospective Cohort Analysis

“…A manual review of charts was conducted based on ICHD criteria (Appendix A). The ICHD lists five specific criteria for diagnosis of MGH with or without aura and episodic TTH based on the elimination of headache as a secondary headache syndrome, frequency and duration of the headache, pain location (unilateral, bilateral), presence of visual disturbances, nausea, and vomiting [ 14 ]. Thirty charts per headache type of interest were reviewed to determine how many ICHD criteria (supplementary materials) were explicitly documented during the index encounter, meaning the first visit to the outpatient clinic during the study period.…”

“…Despite the high prevalence of primary headache syndromes in the published literature, diagnosis remains challenging, and headaches may be underestimated and misdiagnosed. There are myriad publications outlining headache diagnosis in the primary care setting [12][13][14][15], but little information exists on how often diagnoses are made using specific recommended guidelines or documenting diagnosis algorithms in the electronic medical records (EMR) [16].…”

Characteristics associated with response to subcutaneously administered anti‐CGRP monoclonal antibody medications in a real‐world community cohort of persons living with migraine: A retrospective clinical and genetic study

“…Genetic analyses were limited to patients who participated in The DodoNA Project: DNA Predictions to Improve Neurological Health (EH10‐139, NSUHS‐IRB approved April 2011) 54 and provided written informed consent for genotyping and EMR review. We determined responder status from MIDAS Question A for 199 DodoNA participants (90% Caucasian, 95% female) prescribed a CGRP medication.…”

“…The DodoNA Project: DNA Predictions to Improve Neurological Health (EH10-139, NSUHS-IRB approved April 2011) 54 and provided written informed consent for genotyping and EMR review.…”