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Leveraging Electronic Health Records for Guideline-Based Asthma Documentation
Jeremy Landeo-Gutierrez1, Andrew Defante2, Matejka Cernelc-Kohan1
1Division of Respiratory Medicine, Department of Pediatrics, University of California San Diego, Rady Children's Hospital of San Diego, San Diego, Calif.
The Journal of Allergy and Clinical Immunology. in Practice
|December 15, 2022
Summary
Structured asthma templates in electronic health records significantly improve documentation completeness for pediatric asthma care. This enhances adherence to clinical guidelines and potentially impacts treatment outcomes.
Area of Science:
- Pediatric Pulmonology
- Health Informatics
- Clinical Documentation Improvement
Background:
- Asthma is the most prevalent chronic condition in children, necessitating standardized care protocols.
- Clinical guidelines for asthma management emphasize systematic symptom documentation.
- Electronic health records (EHR) offer potential for systematic data capture, but documentation consistency remains a challenge.
Purpose of the Study:
- To determine if structured asthma templates (ASTs) improve guideline-based asthma documentation and clinical outcomes compared to non-structured templates (NSTs).
Main Methods:
- A retrospective case-control study compared ASTs and NSTs in pediatric pulmonology encounters (March 2016-December 2021).
- Guideline-based asthma history items (29 for new, 22 for follow-up) were assessed for completeness.
- Associations with demographics, spirometry, and healthcare utilization were analyzed.
Main Results:
- Use of ASTs correlated with significantly higher documentation rates for asthma history items in both initial and follow-up encounters.
- ASTs increased asthma history completeness by 28.2% (initial) and 39.65% (follow-up) compared to NSTs.
- AST use was linked to increased systemic steroid prescriptions within 12 months; other differences were not significant after adjusting for asthma severity.
Conclusions:
- Asthma-specific structured templates enhance adherence to guideline-based documentation in pediatric care.
- Optimizing EHRs with structured templates can improve clinical practice and research capabilities for asthma management.
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