Implementation of Clinical Guidelines via a Computer Charting System

Objective: The authors have shown that clinical guidelines embedded in an electronic medical record improved the quality, while lowering the cost, of care for health care workers who incurred occupational exposures to body fluid. They seek to determine whether this system has similar effects on the emergency department care of young children with febrile illness. Design: Off-on-off, interrupted time series with intent-to-treat analysis. Setting: University hospital emergency department. Subjects: 830 febrile children less than 3 years of age and the physicians who treated them. Interventions: Implementation of an electronic medical record that provides real-time advice regarding the content of the history and physical examination and recommendations regarding laboratory testing, treatment, diagnosis, and disposition. Measurements: Documentation of essential items in the medical record and after-care instructions; compliance with guidelines regarding testing, treatment, and diagnosis; charges. Results: The computer was used in 64 percent of eligible cases. Mean percentage documentation of 21 essential history and physical examination items increased from 80 percent during the baseline period to 92 percent in the intervention phase (13 percent increase; 95 percent CI, 10-15 percent). Mean percentage documentation of ten items in the after-care instructions increased from 48 percent at baseline to 81 percent during the intervention phase (33 percent increase; 95 percent confidence interval, 28-38 percent). All documentation decreased to baseline when the computer system was removed. There were no demonstrable improvements in appropriateness of care, nor was there evidence that appropriateness worsened. Mean charges were not changed by the intervention. Conclusion: The intervention markedly improved documentation, had little effect on the appropriateness of the process of care, and had no effect on charges. Results for the febrile child module differ from those for the module for occupational blood and body fluid exposure (a more focused and straightforward medical condition), underscoring the need for implementation methods to be tailored to specific clinical complaints.