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The Healthcare Effectiveness Data and Information Set (HEDIS) are measures used to evaluate yearly performance. Their use is required for reimbursement from the Centers for Medicare and Medicaid Services.⁴ The HEDIS guidelines have been recognized as meaningful and important tools for healthcare, and almost 90% of all healthcare systems gather and report HEDIS data.⁵ HEDIS sends quarterly summaries to healthcare practices, known as the HEDIS Physician Practice Report Card. The reports are distributed every 3 months to evaluate adherence to the HEDIS guidelines.

Background

Electronic charting has been referred to as the future of healthcare documentation.⁶ The emphasis of pediatric healthcare has shifted from treatment to prevention and anticipatory guidance.⁷ A component of EHR that could be more beneficial to pediatric patients is the electronic reminder option for anticipatory guidance and prevention guidelines.

Literature Review

Kemper et al⁸ studied the implementation of EHR in pediatric practices by randomly sampling 1,000 pediatricians from the American Medical Association master file. They found that smaller and independent practices were less likely to have EHR in use, and that larger and network practices were more likely to use EHR. For many of the pediatricians, the cost of EHR was a barrier to implementation. Another barrier was the question of whether EHR improves patient care. The study found that smaller and independent practices are unlikely to implement EHR until the cost of this implementation decreases and quality of care is perceived to improve as a direct result.

Roukema et al⁹ compared current paper documentation with electronic documentation of the same information. A sample of four pediatricians documented eight new patient visits using both paper charts and EHR. The researchers used a questionnaire based on the Questionnaire on User Interface Satisfaction to assess the users' experiences with EHR. Electronic documentation of the physical examination was more complete and contained more patient information than the paper documentation.⁹ 

In other research, authors performed a descriptive study to assess the impact of EHR on documentation, clinical processes and patient access in a large urban pediatric primary care clinic.¹⁰ The study audited 500 paper charts preloaded into the EHR system. The researchers concluded that the implementation of EHR improved documentation of patient care, improved clinical processes and increased revenue.

Purpose

We sought to determine if EHR use can provide more detailed and accurate documentation of well child examinations. The goals of the study were to provide better documentation of well child care by implementing EHR in a pediatric practice and to increase adherence to the HEDIS guidelines for well child examinations.

A 2009 HEDIS Physician Practice Report Card for this practice, located in Georgia, stated that it did not regularly document body mass index (BMI), activity and nutrition status. Only a small percentage of patient charts contained current documentation on well child examinations, immunization status and lead screenings. The practice had below-average percentiles on the following requirements for the well child examination: more than six well child examinations by age 15 months, yearly well child examinations from ages 3 to 6, and adolescent well child examinations from ages 12 to 21. The practice had received below-average scores as a result of the shortcomings in data.¹¹

This practice employs one full-time pediatrician and one part-time family nurse practitioner. Both providers perform well child examinations and acute care examinations daily. The study included all well child visits during the 3 months prior to the implementation of EHR and 3 months after the implementation of EHR. Although the pediatric practice has a large percentage of patients with Medicaid insurance, the study included all patients regardless of insurance type or status. All patient visits coded as well child examinations were included, even if a sick visit diagnosis was documented.

Method                                                                                        

We developed a rubric to perform chart reviews and examine the documentation of certain data about well child examinations (see figure). We reviewed the charts representing all well child visits conducted in the 3 months before EHR was implemented. After the adoption of EHR, we reviewed the charts for all well child visits for another 3 months. We used the same rubric to compare documentation before and after the EHR implementation. We assigned a total score to the rubric and compared pre-implementation and post-implementation scores using descriptive statistics and bivariate analysis.

Statistical Analysis

The pre-implementation sample size was 380, and the post-implementation sample size was 479, resulting in a total sample size of 859. Individual surveys were not linked pre- and post-implementation, since the data was aggregate level. Reports of all well child examinations were completed, and all patient records were retrieved. We did not exclude any charts from the study; all well child examinations were included regardless of the patient's insurance status.

Ratio level variables were vital signs, lead testing, weight and height measurement, growth charting, immunizations, health education and guidance, physical exam, and health history. Each variable was scored according to which category was applied. Categories were divided into "no information documented," "partial information documented" and "full information documented." We determined a total score for each patient record. Sociodemographic variables included age and type of insurance.

We used IBM's SPSS Statistics GradPack 17.0 software for the statistical analysis. We determined descriptive statistics for the ratio level variables. The age in months for the pre-implementation data (M = 34.06, SD = 46.35) was higher than the post-implementation data (M = 25.95, SD = 37.28). The total score for pre-implementation data (M = 63.61, SD = 5.50) was lower than the total score for post-implementation data (M = 66.62, SD = 5.00). This increase in the mean total score supported improved patient documentation after the implementation of EHR.

The variable that had the largest increase in documentation was vital signs, which rose from 0.5% pre-implementation to 83.5% post-implementation. The variables of physical examinations and health history each increased to 100% documentation after EHR implementation.            

We also determined inferential statistics. We performed a bivariate analysis using paired sample t-tests to examine the difference in the means before and after implementation. There were no identifiers for the samples and no link between the pre-implementation sample and the post-implementation sample. There was no certainty of the same patient records being reviewed.

The means for total score of chart completion were different (pre-implementation M = 63.58 and post-implementation M = 66.62). A paired samples t-test identified a difference in the pre- and post-implantation chart completion (t = -8.457, p < .0001). The output indicates that the observed difference in the means is significant. A significant increase in patient documentation of well child examinations occurred in the post-implementation data as compared to the pre-implementation data.

Discussion

Both the lead testing and the immunization variables decreased in percentage after EHR implementation. The lead test was only included for public insurance patients between the ages of 12 months and 36 months due to the HEDIS guidelines recommendations. These decreases can be explained by the timing of the chart reviews. Due to time constraints, the post-implementation chart reviews were performed soon after the well child visit. If the lead test was ordered and the results were not in the EHR, only a partial documentation score was given. Since the lead test is done at an outpatient laboratory, it takes about 1 week for results to be faxed to the practice. It then takes another week for the pediatrician to sign off on the lab report and for the report to be scanned or entered into the EHR. Even if the parent took the patient to have the lead test done the same day of the well child exam, the results would not be documented in the EHR for about 2 weeks.

The decrease in immunization percentage was due to the immunization records not being scanned into the EHR. Therefore, documentation was incomplete. Only the immunizations given that day were documented in the EHR. The EHR system has a link to the Georgia Immunization Registry (GRITS), but this link was not installed at the time of EHR adoption. This EHR link allows the practice access to GRITS and places the immunization record from GRITS into the EHR immunization record. If the link had been installed at that time, the immunization percentage would not have decreased because the records would have been up-to-date with the GRITS.

After the data were collected, the EHR system did provide the practice with the link to the GRITS. The EHR is now linked to GRITS, and the problem has been corrected. Another reason the lead test variable and the immunizations variable may have decreased is that the mean age of the post-implementation sample was younger than the mean age of the pre-implementation sample. The mean age for pre-implementation is closer to 3 years, and the mean age for post-implementation is closer to 2 years. These two variables, immunization and lead test, are the only variables that are age-dependent.

Limitations and Unexpected Results

One unexpected result of the study was that the percentages of post-intervention data for fully completed documentation decreased on two other variables. Growth chart documentation decreased by 1.4%, and weight and height documentation decreased by 0.8%. The growth chart variable is dependent on the weight and height variable. If the weight and height variable is not completed, the growth chart variable cannot be completed.

One limitation of the study is a result of time constraints. The post-implementation data was retrieved immediately after the EHR was implemented. This could account for the decrease in immunization percentages because all immunization records had not been scanned into the EHR. This is also true for the decrease in lead percentages, because not enough time had lapsed to retrieve and document the results. Suggestions for future studies would include allowing a trial period of EHR implementation and allowing enough time for the lab tests to be entered into the chart before collecting data.

In conclusion, implementing EHR in a pediatric office is beneficial for patients, providers and other healthcare organizations. Patients benefit from EHR by more accurate documentation and safer prescribing techniques. Providers benefit because they can offer more effective and safer care and can decrease the time and personnel required to retrieve and file paper charts. EHR can benefit all healthcare organizations by improving the quality of healthcare and decreasing its associated costs.

Kelli Whitted is a family nurse practitioner who is an assistant professor in the Troy University School of Nursing in Troy, Ala. Aimee Vael is a family nurse practitioner who is an associate professor in the Troy University School of Nursing.

References

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