Problem Specific Templates for Electronic Hospital Documentation

Study Overview
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Brief Summary
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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
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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.

Official Title
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Problem Specific Templates for Electronic Hospital Documentation

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

Intervention / Treatment
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* Other: Hospitalists


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Physicians: All physicians of the Hospital Medicine Service will be invited to participate Exclusion Criteria: Any invited physicians who refuse to consent

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 70 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Hospitalists<br>Introduction of Problem Specific Templates | Other: Hospitalists<br>* Introduction of Problem Specific Templates<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| 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

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Frequency of Physician Use of Problem Specific Templates (as measured through chart review) |  | 1 year | 
| Physician Assessment of Note-Documenting and Electronic Medical Record (as measured through Physician Questionnaire) |  | 1 year | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Problem Specific Template, Physician Documentation, Electronic Medical Record Documentation