The Use of a Structured Documentation to Improve Adherence to Clinical Guidelines

Introduction. Research has shown that structured documentation, like prepopulated “dot phrases,” can improve quality measures when compared to free text or dictation. This has been attributed to clinicians interacting more with the electronic health record (her), pre-populated clinical decision support, and increased speed of documentation. However, clinicians reported less satisfaction with this method, with redundant notes and excessive copy and paste. The study evaluated the utility of an initial obstetrical (IOB) structured documentation to prompt physicians to appropriately recommend aspirin for preeclampsia prevention and to improve compliance with clinical guidelines.

Methods. The study was conducted at two local clinics, which used an updated “dot phrase” for IOB visits, with the updated USPSTF recommendations on aspirin use in pregnancy. We reviewed data on patients with their IOB appointment, pre-, post-, and 6-months following implementation of the dot phrase. 306 charts were reviewed by two groups of two reviewers during the study period. The current ACOG guidelines for assessing pre-eclampsia risk were used in determining risk and appropriate aspirin usage. Cohen’s kappa coefficient (κ) measured the reviewers’ inter-rater agreement for the charts reviewed. Authors used standard descriptive statistics to calculate the number of OB patients at risk for pre-eclampsia and those who received aspirin. We used cumulative risk, rate ratio, and percentage relative effect to determine if structured documentation prompted appropriate aspirin use.

Results. The Cohen’s κ calculation showed agreement between the two groups of raters, κ=.908 (95% CI, 0.84 to 0.98), P<.0001. 103 IOB visits occurred prior to the intervention. 59 patients were at risk of preeclampsia, 11 (17%) were recommended aspirin. 102 IOB visits occurred after the intervention. 43 patients were at risk for pre-eclampsia, 34 (79%) were recommended aspirin. 101 IOB visits occurred 6-month after the intervention. 42 patients were at risk for pre-eclampsia, 39 (93%) were recommended aspirin.

Conclusion. Our data showed that IOB structured documentation improved the appropriate use of aspirin for pre-eclampsia prevention and patient care. Overall, the findings of this study suggest that structured documentation is an effective tool in improving clinical practice and patient outcomes. Future studies should address clinician dissatisfaction with redundancy with the structured documentation.