Structured clinical documentation in the electronic medical record to improve quality and to support practice-based research in epilepsy

Abstract

Objective: Using the electronic medical record (EMR) to capture structured clinical data at the point of care would be a practical way to support quality improvement and practice-based research in epilepsy.

Methods: We describe our stepwise process for building structured clinical documentation support tools in the EMR that define best practices in epilepsy, and we describe how we incorporated these toolkits into our clinical workflow.

Results: These tools write notes and capture hundreds of fields of data including several score tests: Generalized Anxiety Disorder-7 items, Neurological Disorders Depression Inventory for Epilepsy, Epworth Sleepiness Scale, Quality of Life in Epilepsy-10 items, Montreal Cognitive Assessment/Short Test of Mental Status, and Medical Research Council Prognostic Index. The tools summarize brain imaging, blood laboratory, and electroencephalography results, and document neuromodulation treatments. The tools provide Best Practices Advisories and other clinical decision support when appropriate. The tools prompt enrollment in a DNA biobanking study. We have thus far enrolled 231 patients for initial visits and are starting our first annual follow-up visits and provide a brief description of our cohort.

Significance: We are sharing these EMR tools and captured data with other epilepsy clinics as part of a Neurology Practice Based Research Network, and are using the tools to conduct pragmatic trials using subgroup-based adaptive designs.

Keywords: Best practices; Clinical decision support; Electronic medical record; Epilepsy; Outcomes; Pragmatic trials; Structured clinical documentation support.

Figure 1

Structured clinical document support toolkit. Quality improvement and practice‐based research in epilepsy using the electronic medical record (EMR) consists of a stepwise progression from the development and implementation of a structured clinical documentation support (SCDS) toolkit (including note writing and electronic data capture); to enrollment reports; to data quality reports (and data cleaning); to descriptive reports of cohort characteristics; to quality improvement projects (including the creation of benchmark data and quality improvement dashboards); to the use of clinical decision support tools (to hardwire patient safety and improved outcomes); to other research (e.g., biobanking of DNA and the association of genotypes with longitudinal outcomes, pragmatic trials using subgroup adaptive design). The EMR provides a framework for measuring and impacting the three dimensions of quality improvement: structure, process, and outcomes.

Figure 2

Screenshots of the SDCD toolkits within the EMR, ©2015 EPIC Systems, used with permission. (A) Screenshot of spells/seizure data collection, (B) screenshot of diagnostic imaging data collection, (C) screenshot of EEG data collection, (D) screenshot of MRC Prognostic Index data collection. Additional screenshots are available in Data S1.