Objective: The objective was to determine the effect of an electronic asthma-specific inpatient history and physical (H&P) template on documented history and improvements in care plans.
Methods: This was a before-after comparison of history and care plan documentation following implementation of a new H&P template. The template was implemented in May 2011. A retrospective review of the electronic health record was completed for 304 consecutive patients (2–16 years of age) admitted for asthma June to September 2010 and 242 admitted June to September 2011. Elements reviewed included asthma severity classification, utilization history (previous oral steroids, emergency visits, hospitalizations, intensive care admissions, and intubations), and environmental history (exposure to cockroaches, rodents, and mold). Assessed changes in care plans included social work or asthma-related subspecialty consult and change in controller medications. Patients from 2011 were compared with those from 2010 by using t test and χ2 statistics with adjustment for confounders by use of logistic regression. Interrupted time-series analyses assessed variability in documentation over time.
Results: In 2011, the new H&P template was used in 74% of encounters. Compared with patients seen preimplementation, documentation in those seen after implementation was more likely to include severity classification (71% vs 44%; P < .0001), complete utilization history (73% vs 12%; P < .0001), and environmental history (66% v. 2%; P < .0001). Documentation became more consistent over time. Changes in care planning were also more common after implementation (63% vs 49%; P = .0006).
Conclusions: A structured H&P template for asthma led to more complete and less variable documentation of important history and likely led to enhancements in care plans.
Appropriate and evidence-based care plans rely on clinicians’ ability to identify and document accurate and relevant information. Templates, structured encounter forms, and decision support have led to improved documentation and reduced variability in both paper and electronic charting.1–9 The “meaningful use” of electronic health records (EHRs) aims to use electronic infrastructure to improve the safety, quality, and efficiency of care.10 Computerized documentation support guided by practice guidelines increases physician compliance with care standards.11
Asthma is one of the most common chronic diseases of childhood.12 Clinical guidelines play a particularly important role for children hospitalized for asthma. Recently updated evidence-based guidelines for children admitted with an asthma exacerbation highlight the importance of addressing chronic as well as acute management.13
Our institution recently accelerated the development and expansion of services to improve outcomes for children admitted for asthma. For patients to be connected with appropriate interventions to address chronic asthma management, reliable and accurate screening has become even more crucial. This article focuses on efforts to standardize and improve asthma-related documentation in a newly implemented EHR to efficiently connect patients to our institution’s portfolio of interventions. The specific objective was to determine the effect of an electronic asthma-specific inpatient history and physical (H&P) template, hypothesizing that the template would improve documented history, decrease documentation variability, and lead to appropriate changes in care plans.
This was a before-after comparison of history and care plan documentation following implementation of a new H&P template. We reviewed EHR documentation on 304 consecutive patients (2–16 years of age) admitted for asthma from June to September 2010 and 242 consecutive patients from June to September 2011. Subjects were identified based on admission diagnosis (International Classification of Diseases, 9th Revision, Clinical Modification 493.XX) and use of the evidence-based pathway for acute asthma care by the admitting physician. Quality assurance data show that this pathway is used for >98% of children admitted for asthma exacerbation to our institution. We excluded patients who were removed from the pathway after initial diagnostic consideration by the inpatient attending physician. Other exclusion criteria included cystic fibrosis and congenital heart defects. This study was approved by the Cincinnati Children’s Hospital Medical Center (CCHMC) Institutional Review Board.
CCHMC is a 425-bed, urban, pediatric academic hospital that trains ∼150 pediatric residents each year. Approximately 1500 patients are hospitalized at CCHMC for an asthma exacerbation annually with most seen initially by pediatric residents who staff patients with attending physicians, >80% of whom are pediatric hospitalists.
In 2008, CCHMC began a long-term project to improve outcomes for patients with asthma cared for in our system. Before implementation of an EHR, a paper asthma-specific H&P template was piloted (August 2009 to January 2010), significantly increasing rates of pertinent documentation. In January 2010, the institution transitioned to an EHR. After the transition, several different asthma-related H&P templates, variable in use, quality, and asthma specificity, were available. None prompted specific interventions directed at chronic disease management.
In September 2010, an updated CCHMC Evidence-Based Care Guideline for Management of an Acute Asthma Exacerbation was published.13 Publication coincided with ongoing institutional efforts to improve outcomes that focused on the initiation or modification of chronic care management plans during hospitalization. Highlights of these efforts included targeted social work referrals, asthma-related subspecialty (allergy and pulmonology) consultations, and provision of severity-appropriate controller medications for home use before discharge. A home health pathway was also developed at this time that involved nurse home visits focusing on adherence and self-management. An additional home-based intervention involving referrals to the local health department for housing code enforcement for patients exposed to cockroaches, rodents, or mold was also being piloted during the summer of 2011. A structured asthma-specific H&P template based on the revised guideline13 and the paper-based pilot work was designed to reliably identify risks and make appropriate referrals to these existing and evolving resources.
Planning and Executing the Intervention
In January 2011, a multidisciplinary team of physicians, nurses, respiratory therapists, asthma care coordinators, and community partners at the Cincinnati Health Department assembled to identify key items to include in the new H&P template. Information technology specialists then created an electronic version.
During May 2011, pediatric residents from 2 of the 5 general pediatric inpatient teams used and critiqued the H&P template. Changes were made based on feedback, and a final version was available by the end of May (Fig 1). On June 1, previous templates, inconsistently used for asthma admissions, were removed from the EHR. Meetings with each of the general pediatric inpatient resident teams took place to describe the H&P template and its foundation in both the revised guideline and local improvement efforts. Further initiatives aimed at uptake were pursued during the summer of 2011 with non-ICU teams and included educational outreach and data sharing.
Outcome Measures and Methods of Evaluation
Documentation of asthma severity classification, chosen for its relevance in the tailoring of chronic asthma medication regimens, was identified as present or absent. Utilization history was defined as presence or absence of a documented history of need for oral steroids, asthma-related emergency department visitation, hospitalization, ICU admission, and intubation. Documented presence of all 5 was also assessed. Each item was thought to be relevant to inpatient care and discharge planning, including referrals to subspecialists and the home health pathway. Documentation of exposure to cockroaches, rodents, and mold was assessed. At the time of H&P template development, social work referral was the primary intervention used when risks were identified, but the aforementioned partnership with the local health department for code enforcement was being actively developed.
Change in initial care planning was assessed through review of the plan from the resident H&P and documentation by the attending physician who staffed the admission. We did not review beyond these notes (eg, notes on subsequent days or the discharge summary) to take a conservative approach in assessing the H&P template’s impact on care plans. We identified 3 items specific to CCHMC improvement efforts. Specifically, we assessed documented intent to obtain a social work referral, request an allergy or pulmonology consult, or initiate or change asthma controller medications (defined as inhaled corticosteroids, montelukast sodium, or combination corticosteroid/long-acting β-agonist). A summary variable was created to assess whether a plan for any one or more of the 3 changes was documented.
Demographic variables collected included age, gender, race, and insurance. Interval of albuterol at the time of admission was collected as a proxy for exacerbation severity, comparing those requiring albuterol at or more frequently than every hour with those requiring albuterol at or less frequently than every 90 minutes. At our institution, the severity of exacerbation, and initial interval of albuterol, is determined by symptoms, physical examination, pulse oximetry, and peak flow (if performed). Those in severe exacerbation are provided with continuous albuterol treatment. Those in moderate exacerbation are provided with hourly albuterol treatments; those in mild exacerbation are provided with albuterol at or less frequently than every 90 minutes.13,14 In addition, use of an asthma controller medication at admission was recorded along with asthma-related hospitalizations in the previous 12 months. Charts were reviewed by 3 trained research personnel by use of a standardized data collection tool.
Before and after implementation sample characteristics were compared by using t tests for continuous variables and χ2 statistics for categorical variables. All patients from the 2010 study period were compared with all those from the 2011 study period. This analysis was pursued to limit confounding by indication, considering that clinicians might have chosen to use or not use the H&P template based on clinical and/or social characteristics of a child’s initial presentation.15 Bivariate analyses were conducted by using χ2 statistics. Logistic regression was used to adjust for age, gender, insurance, interval of albuterol at admission, and previous hospitalization. A number needed to change (NNC) was calculated from the inverse of the absolute difference in documented change in care plans between those enrolled before and after H&P template implementation. NNC was conceptualized as the number of H&Ps that needed to be completed for 1 child to have an initial care plan change. Similar subanalyses were completed comparing only those receiving the H&P template in June to September 2011 with all patients from the June to September 2010 cohort.
To best depict and understand variability and trends over time, processes were tracked with annotated run charts, a visual depiction of our interrupted time-series analyses. Run charts can be used to differentiate common-cause and special-cause variation. Common-cause variation is the typical variation that occurs within a stable process. Special-cause variation results from specific changes in process.16 There are well-defined quantitative rules to determine special cause on run charts. One key rule is when there are 8 consecutive points above or below the previously established median.16 We were interested in identifying if special-cause variation and/or a reduction in common-cause variation could be attributed to implementation of the H&P template.
The 304 patients enrolled in 2010 were no different than the 242 enrolled in 2011 with regard to gender, race, or severity at admission (Table 1). Patients admitted in 2011 were slightly younger (6.6 vs 6.8 years; P = .02), more likely to be publically insured (80% vs 71%; P = .02), and more likely to have a previous hospitalization (42% vs 32%; P = .01). A total of 74% of patients in 2011 were admitted by using the H&P template. Uptake in template use was rapid with stabilization around a median of 87% occurring 2 weeks after implementation (Fig 2).
Table 2 compares all patients sampled in 2011 with all sampled in 2010. Documentation of severity classification (71% vs 44%; P < .0001), a complete utilization history (73% vs 12%; P < .0001), and a complete environmental history (66% vs 2%; P < .0001) were all significantly higher in 2011. Adjustment for age, gender, insurance, presenting severity, and previous hospitalization did not change effect estimates.
Similar trends were noted when children admitted in 2011 and 2010 were compared with respect to changes in care plans (Table 3). Children in 2011 were significantly more likely to receive a social work referral, subspecialty consultation, or change in medication regimen in comparison with children in 2010 (63% vs 49%; P = .0006). Adjustment for potential confounders did not change effect estimates. Although the NNCs for social work referral and medication change were >10, the NNC for any change was 7.1, suggesting that 7 children would have needed to be admitted in 2011 for 1 child to benefit from an initial care plan change.
A subsequent analysis compared just those receiving the H&P template in 2011 (n = 178) with all sampled in 2010. In 2011, those receiving the H&P template were no different than those not receiving the template in terms of gender, insurance, and age; however, they were more likely to be black (69% vs 44%, P = .002), less likely to require albuterol every hour or more (63% vs 78%, P = .04), and more likely to have been previously hospitalized (47% vs 30%, P = .02). The majority (64%) of those not receiving the H&P template in 2011 were initially admitted to the ICU where its use was not being actively encouraged. Compared with all children sampled in 2010, those receiving the H&P template in 2011 were more likely to have a documented severity classification (84% vs 44%; P < .0001), a complete utilization history (94% vs 12%; P < .0001), and a complete environmental history (87% vs 2%; P < .0001) (Table 4). Any change in care plan was significantly more likely to occur among those receiving the H&P template in 2011 (67% vs 49%; P < .0001). The NNCs for all changes in care plans were ≤10. Adjustment for potential confounders had no impact on the size of effect. Those not receiving the H&P template in 2011 (n = 74) showed no differences in documented history or changes in care plans compared with those sampled in 2010.
Variability and Trends Over Time
Figure 3 illustrates the increased rate of documentation of key historical items over time. The median documentation rate for severity classification increased from 50% to 73%, previous steroid use from 36% to 80%, and cockroach exposure from 9% to 67%. In each case, special-cause criteria were met within the first few weeks of the 2011 study period. In addition, the run charts depict decreasing variability over time. Points become more tightly clustered around the median line the longer the H&P template was available and consistently used.
Implementation of a standardized and structured asthma-specific inpatient H&P template was associated with a 60% increase in documented asthma severity classification, a sixfold increase in documentation of asthma-related utilization history, a 29-fold increase in documentation of environmental history, and a 30% increase in the documentation of initial change in care plans. Moreover, implementation of the H&P template reduced the variability with which certain items were documented, providing additional evidence that implementation of standardized tools improves process reliability.
Previous work has suggested that templates and structured encounter forms improve documentation, yet findings have been largely focused in the primary care setting. Davis et al6 showed improvements in documented severity classification from 24% to 44% before and after implementation of an electronic outpatient asthma template in a family medicine practice. In our inpatient pediatric population, we too saw significant increases in severity classification. We believe the increase from 44% to 71% was driven almost entirely by the H&P template, because previous work in our institution that contributed to severity classification was well-established and stable by 2010.
Health outcomes are driven by appropriate and relevant care plans. Bell et al9 demonstrated a 6% increase in prescriptions for asthma controller medications within pediatric primary care sites randomly selected to receive EHR-embedded decision support. We, too, saw changes in care planning, including a change in controller regimens after implementation of the H&P template. This is a powerful finding given that our study took place on the inpatient unit, among children who are potentially at very high risk. Although our data cannot assess whether the H&P template led directly to improvements in health outcomes, we do expect that it increased the likelihood of the right care plan being provided to the right patient.
The H&P template included potentially sensitive social and environmental questions but was designed with both evidence and interventions in mind.13 Previous work has highlighted the reluctance to ask certain questions, especially when there is no perceived fix.17,18 Thus, the sensitive questions were included only if potential interventions existed or if answers might impact clinical decision-making (eg, to help interpret a patient’s lack of adherence to previous medication prescriptions). Qualitatively, we found that having tangible interventions eased barriers to buy-in from both clinicians and families, especially when social and environmental history questions were involved.19
Determining how an EHR fits into an academic environment has been a challenge,20 but we believe templates can be both clinical and educational resources, especially in the management of acute manifestations of chronic disease. Our asthma-specific H&P template was created to efficiently and reliably guide discussions surrounding a child’s acute and chronic care. In addition to highlighting evidence-based guidelines for management of an acute asthma exacerbation, the plan section highlighted interventions that might prevent readmissions. We expect that embedded prompts used on 1 patient may guide evidence-based practice on subsequent patients.
Evidence-based practice requires reliable systems that put evidence in the hands of the clinician.21 To realize improvement in performance reliability, we sought feedback from front-line clinicians before and after implementation. We also emphasized educational outreach to explain the H&P template’s rationale; we shared data and eliminated alternative templates.22 Implementation strategies were designed to maximize key stakeholder buy-in and allow for H&P template utilization to occur within preexisting clinician work flows. Such efforts led to reduced variability in history taking and further standardized inpatient asthma care. Standardization has been shown to improve patient outcomes, and reductions in unwarranted variation can increase adherence to evidence-based practice.23,24
This study was not without limitation. First, a secular trend, or ongoing improvement efforts, may have altered results at baseline between 2010 and 2011. Still, those not receiving the H&P template in 2011 showed no differences in assessed outcomes compared with those from 2010. In addition, when just those receiving the H&P template in 2011 were compared with all sampled in 2010, the size and consistency of the effect increased.
Second, the choice to use or not to use the H&P template may not be random. The comparison of all patients sampled in 2011 with all sampled in 2010 should minimize the effect this may have, and, if anything, bias findings toward the null.
Third, we were unable to report subsequent asthma control or asthma-related acute health service utilization. In addition, documentation of plans in any H&P may not always have led to interventions actually happening. Therefore, we cannot address the effect more complete histories and changes in care plans may have had on postdischarge asthma morbidity.
Fourth, there were differences between patients admitted in 2011 and 2010. For example, patients admitted in 2011 were more likely to report previous hospitalization. We are unable to tell, from these data, whether such a difference made caregivers more (or less) likely to volunteer relevant historical information.
Finally, our sample was limited to a single institution with a strong philosophical and financial commitment to asthma improvement efforts. Also, the electronic H&P template had been preceded by a paper version before EHR transition. Consequently, our baseline and postimplementation findings may not be generalizable to populations in other regions or at other institutions.
Patient-level outcomes must be evaluated for those receiving the H&P template and connected to the new interventions. In addition, the H&P template should continue to adapt to changing evidence and availability of resources. Templates devoted to other common pediatric conditions could also be developed and tested with similar processes.
Use of a specific and structured H&P template for asthma was associated with more complete and less variable documentation of important history elements and likely led to associated changes in care plans. The use of inpatient templates to target and inform evidence-based assessments and interventions is a potential strategy to improve the health of children with poorly controlled chronic disease.
All 6 of the authors are responsible for the reported research and participated in the concept and design, analysis and interpretation of data, and drafting of the manuscript. Each author had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: This project was supported by funds from the Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS), under the Cincinnati Children’s Hospital Medical Center (CCHMC) NRSA Primary Care Research Fellowship in Child and Adolescent Health (T32HP10027). The information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by the BHPR, HRSA, DHHS or the US Government (Beck). Database assembly was supported by a Center for Clinical and Translational Science and Training (CCTST) Community Health Program Grant to Promote Academic-Community Collaboration and Positive Health Outcomes (PI: Beck, Kahn; Co-I: Simmons), a CCHMC Outcomes Research Award (PI: Simmons; Co-I: Beck, Kahn), and the Greater Cincinnati Asthma Risks Study, funded via NIH 1R01AI88116 (PI: Kahn; Co-I: Simmons, Beck). Support was also provided under cooperative agreement 90BC0016-01 from the Office of the National Coordinator for Health Information Technology of the US Department of Health and Human Services (Simmons, Sauers). The project described was supported by the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant 8 UL1 TR000077-04. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
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- Copyright © 2012 by the American Academy of Pediatrics