The effect of standardized, computer-guided templates on quality of VA disability exams.
BACKGROUND
The costs and limitations of clinical encounter documentation using dictation/transcription have provided impetus for increased use of computerized structured data entry to enforce standardization and improve quality. The purpose of the present study is to compare exam report quality of Veterans Affairs (VA) disability exams documented by computerized protocol-guided templates with exams documented in the usual fashion (dictation).


METHODS
Exam report quality for 17,490 VA compensation and pension (C&P) disability exams reviewed in 2005 was compared for exam reports completed by template and exam reports completed in routine fashion (dictation). An additional set of 2,903 exams reviewed for quality the last three months of 2004 were used for baseline comparison.


RESULTS
Mean template quality scores of 91 (95% CI 89, 92) showed significant improvement over routine exams conducted during the study period 78 (95% CI 77, 78) and at baseline 73 (95% CI 72, 75). The quality difference among examination types is presented.


CONCLUSIONS
The results of the present study suggest that use of the standardized, guided documentation templates in VA disability exams produces significant improvement in quality compared with routinely completed exams (dictation). The templates demonstrate the opportunity and capacity for informatics tools to enhance delivery of care when operating in a health system with a sophisticated electronic medical record.
Fielstein
Elliot M
EM
Department of Veterans Affairs, Nashville, TN, USA.
Brown
Steven H
SH
McBrine
Caroll S
CS
Clark
Terry K
TK
Hardenbrook
Shawn P
SP
Speroff
Ted
T
D004185:Disability Evaluation; D005568:Forms and Records Control; D006801:Humans; D016347:Medical Records Systems, Computerized; D010415:Pensions; D011785:Quality Assurance, Health Care; D014481:United States; D014493:United States Department of Veterans Affairs; D014584:User-Computer Interface; D014729:Veterans Disability Claims; D014942:Workers' Compensation