Use of electronic medical record templates improves quality of care for patients with infantile spasms

Santoro, Jonathan D.; Sandoval, Amanda; Ruzhnikov, Maura R.Z.; Brimble, E.; Chadwick, Whitney; Wusthoff, Courtney J.

doi:10.1177/1833358318794501

Cited by 8 publications

(7 citation statements)

References 12 publications

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“…For two NCP steps: Nutrition Intervention, and Nutrition Monitoring and Evaluation, this was confirmed through an association between the existence of pre-set EHR pre-defined headings and the implementation level of standardised NCPT terms. Structured templates in the EHR have been shown to improve quality of both the clinical documentation and the care given (Santoro et al, 2021; Vetter and Kim, 2021). The design of intuitive data entry interfaces, such as autocomplete functions, abbreviation and acronym expansion (Lee et al, 2013), or check boxes and drop-down lists (Bennett and Steen, 2010), have been suggested as important implementation strategies for the SNOMED CT terms.…”

Section: Discussionmentioning

confidence: 99%

“…Facilitation includes the role of a person, either external or internal, supporting the implementation of changes in practice (Harvey and Kitson, 2016). Technological aspects such as compatibility with existing terminologies or EHR systems have been highlighted as key to implementation of standards in healthcare documentation (Vetter and Kim, 2021;Lee et al, 2013;Bennett and Steen, 2010;Santoro et al, 2021;Fennelly et al, 2021;Højen et al, 2014;Liu et al, 2010). Further, access to the EHR has been pointed out as a possible enabler for NCPT implementation among dietitians, both in an Australian study from 2013 and in a global survey from 2020 (O'Sullivan, 2013;Lövestam et al, 2020).…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Individual and contextual factors in the Swedish Nutrition Care Process Terminology implementation

Lövestam

Orrevall

Boström

2022

HIM J

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Background Standardised terminologies and classification systems play an increasingly important role in the continuous work towards high quality patient care. Currently, a standardised terminology for nutrition care, the Nutrition Care Process (NCP) Terminology (NCPT), is being implemented across the world, with terms for four steps: Nutrition Assessment (NA), Nutrition Diagnosis (ND), Nutrition Intervention (NI) and Nutrition Monitoring and Evaluation (NME). Objective To explore associations between individual and contextual factors and implementation of a standardised NCPT among Swedish dietitians. Method A survey was completed by 226 dietitians, focussing on: (a) NCPT implementation level; (b) individual factors; and (c) contextual factors. Associations between these factors were explored through a two-block logistic regression analysis. Results Contextual factors such as intention from management to implement the NCPT (OR (odds ratio) ND 15.0, 95% Confidence Interval (CI) 3.9–57.4, NME 3.7, 95% CI 1.1–13.0) and electronic health record (EHR) headings from the NCPT (OR NI 3.6, 95% CI 1.4–10.7, NME 3.8, 95% CI 1.1–11.5) were associated with higher implementation. A positive attitude towards the NCPT (model 1 OR ND 3.8, 95% CI 1.5–9.8, model 2 OR ND 5.0, 95% CI 1.4–17.8) was also associated with higher implementation, while other individual factors showed less association. Conclusion Contextual factors such as intention from management, EHR structure, and pre-defined terms and headings are key to implementation of a standardised terminology for nutrition and dietetic care. Implications for practice Clinical leadership and technological solutions should be considered key areas in future NCPT implementation strategies.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Individual and contextual factors in the Swedish Nutrition Care Process Terminology implementation

Lövestam

Orrevall

Boström

2022

HIM J

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“…Bremond-Gignac et al showed the benefit of an ophthalmology-specific EMR for collecting a comprehensive ocular visual phenotype useful for clinical research 18 . Other approaches consisted in adding disease oriented predefined templates to existing EHRs, for example "infantile spasms template" 19 . On the other hand, a horizontal approach would consist in finding a way to explore all the diseases, including rare diseases, in a common format.…”

Section: Structured Ehrs For Translational Researchmentioning

confidence: 99%

Electronic health records for the diagnosis of rare diseases

Garcelon¹,

Burgun²,

Salomon³

et al. 2020

Kidney International

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“…Given the ubiquity and ease of developing templated notes to facilitate documentation within the EHR among practicing clinicians, residents, and students in many countries, creation of a templated note guiding students through the H&P 360 domains could be one approach to promote uptake. EHR-based template studies to date have focused on inpatient resident and faculty subjects with primary endpoints including note quality, quality of care, and time to note completion [12][13][14]. However, few studies have evaluated the use of templates to intentionally improve documentation related to patient perspectives and social and behavioral determinants of health [15,16]; most such initiatives have centered on interprofessional team members rather than on promoting psychosocial documentation within a physician's scope of work [17,18].…”

Section: Introductionmentioning

confidence: 99%

Implementation of a Biopsychosocial History and Physical Exam Template in the Electronic Health Record: Mixed Methods Study

Rieger¹,

Anderson²,

Press³

et al. 2023

JMIR Med Educ

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Background Patients’ perspectives and social contexts are critical for prevention of hospital readmissions; however, neither is routinely assessed using the traditional history and physical (H&P) examination nor commonly documented in the electronic health record (EHR). The H&P 360 is a revised H&P template that integrates routine assessment of patient perspectives and goals, mental health, and an expanded social history (behavioral health, social support, living environment and resources, function). Although the H&P 360 has shown promise in increasing psychosocial documentation in focused teaching contexts, its uptake and impact in routine clinical settings are unknown. Objective The aim of this study was to assess the feasibility, acceptability, and impact on care planning of implementing an inpatient H&P 360 template in the EHR for use by fourth-year medical students. Methods A mixed methods study design was used. Fourth-year medical students on internal medicine subinternship (subI) services were given a brief training on the H&P 360 and access to EHR-based H&P 360 templates. Students not working in the intensive care unit (ICU) were asked to use the templates at least once per call cycle, whereas use by ICU students was elective. An EHR query was used to identify all H&P 360 and traditional H&P admission notes authored by non-ICU students at University of Chicago (UC) Medicine. Of these notes, all H&P 360 notes and a sample of traditional H&P notes were reviewed by two researchers for the presence of H&P 360 domains and impact on patient care. A postcourse survey was administered to query all students for their perspectives on the H&P 360. Results Of the 13 non-ICU subIs at UC Medicine, 6 (46%) used the H&P 360 templates at least once, which accounted for 14%-92% of their authored admission notes (median 56%). Content analysis was performed with 45 H&P 360 notes and 54 traditional H&P notes. Psychosocial documentation across all H&P 360 domains (patient perspectives and goals, mental health, expanded social history elements) was more common in H&P 360 compared with traditional notes. Related to impact on patient care, H&P 360 notes more commonly identified needs (20% H&P 360; 9% H&P) and described interdisciplinary coordination (78% H&P 360; 41% H&P). Of the 11 subIs completing surveys, the vast majority (n=10, 91%) felt the H&P 360 helped them understand patient goals and improved the patient-provider relationship. Most students (n=8, 73%) felt the H&P 360 took an appropriate amount of time. Conclusions Students who applied the H&P 360 using templated notes in the EHR found it feasible and helpful. These students wrote notes reflecting enhanced assessment of goals and perspectives for patient-engaged care and contextual factors important to preventing rehospitalization. Reasons some students did not use the templated H&P 360 should be examined in future studies. Uptake may be enhanced through earlier and repeated exposure and greater engagement by residents and attendings. Larger-scale implementation studies can help further elucidate the complexities of implementing nonbiomedical information within EHRs.

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Use of electronic medical record templates improves quality of care for patients with infantile spasms

Abstract: The use of protocolised EMRTs may improve the quality of patient care in IS and other rare diseases.

Cited by 8 publications

References 12 publications

Individual and contextual factors in the Swedish Nutrition Care Process Terminology implementation

Individual and contextual factors in the Swedish Nutrition Care Process Terminology implementation

Electronic health records for the diagnosis of rare diseases

Implementation of a Biopsychosocial History and Physical Exam Template in the Electronic Health Record: Mixed Methods Study

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