A new initiative based on the electronic medical record, where structured, clinical documentation is used to improve the quality of patient care and improve practice-based research, has been implemented in specialty headache clinics with positive results, according to research published in Headache: The Journal of Head and Face Pain.
The authors built a customized structured clinical documentation support toolkit that collects hundreds of fields of discrete, standardized data. The toolkit was developed to navigate care according to Best Practices and to ensure that care conforms to published quality guidelines.
Headache office visit types were standardized into initial visits, interim visits, and annual visits. A number of assessment tools were included as well, such as the Generalized Anxiety Disorder-7 item, the Center for Epidemiologic Studies Depression Scale, the Insomnia Severity Index, the Migraine Disability Assessment Questionnaire, and the Migraine Specific Quality of Life.
The toolkit collects clinical features, such as headache frequency, timing, triggers, and includes the ability to input free text to add additional details. Abortive and Preventive medication data can be recorded, as well as data for alternative therapies. Imaging data and laboratory results are discretized. Fields for the impression have been designed to be used according to International Classification of Headache Disorders 3. The toolkit was designed for a workflow that includes a medical assistant, neurologist, and possible research assistant. Best Practice Advisories alert physicians on screening results and allow for quick links to referrals and other options. The toolkit also supports clinical research enrollment, data from the toolkit can be used to determine eligibility for research.
Some limitations exist, such as the workflow design which may prove difficult to adapt in other practices. Patient visits were standardized to 60 minutes which may not reflect visit times for other practices as well.
The authors conclude by proposing their toolkit as a model for similar electronic medical record-based quality improvement and practice-based research initiatives.
Meyers S, Simon KC, Bergman-Bock S, et al. Structured clinical documentation to improve quality and support practice-based research in headache [published online August 1, 2018]. Headache. doi: 10.1111/head.13348