Clinical trial NCT01958723: Problem Specific Templates for Electronic Hospital Documentation
Official title: Problem Specific Templates for Electronic Hospital Documentation
Study type: OBSERVATIONAL
Overall status: COMPLETED
Conditions: Quality/Accuracy of Physician Documentation
Efficiency of Physician Documentation
Keywords: Problem Specific Template
Physician Documentation
Electronic Medical Record Documentation
Lead sponsor: University of Florida
Sponsor class: OTHER
First posted: 2013-10-09
Enrollment: 10
Sex: ALL
Minimum age (years): 18
Maximum age (years): 70
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: yes
Observational model: COHORT
Time perspective: PROSPECTIVE
Sampling method: NON_PROBABILITY_SAMPLE
Study population: Physicians of the Hospital Medicine Service

Brief summary: 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: 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.

Eligibility criteria: Inclusion Criteria:

* Physicians: All physicians of the Hospital Medicine Service will be invited to participate

Exclusion Criteria:

* Any invited physicians who refuse to consent

Primary outcomes:
measure: Quality and Accuracy of Physician Documentation Practices (as measured through chart review)
timeFrame: 1 year
measure: Efficiency of Physician Documentation Practices (as measured through the electronic medical record auditing function)
timeFrame: 1 year
Secondary outcomes:
measure: Frequency of Physician Use of Problem Specific Templates (as measured through chart review)
timeFrame: 1 year
measure: Physician Assessment of Note-Documenting and Electronic Medical Record (as measured through Physician Questionnaire)
timeFrame: 1 year
Other outcomes:
Locations:
city: Gainesville
country: United States
facility: University of Florida
state: Florida
Study officials:
affiliation: University of Florida
name: Raj Mehta, M.D.
role: PRINCIPAL_INVESTIGATOR
affiliation: University of Florida
name: Robert Leverence, M.D.
role: STUDY_CHAIR
References: