Implementing standardized provider documentation in a tertiary epilepsy clinic

Implementing Guidelines and Measures in Epilepsy Care

ABSTRACT

People with epilepsy must receive up-to-date, high-quality care that aligns with current understanding of basic disease mechanisms, improved diagnostic testing, and evolving medical and surgical treatments. Varying progress has been made in identifying, measuring, and mitigating epilepsy care gaps. Epilepsy guidelines and quality measures should be developed using rigorous processes informed by systematic reviews of best evidence in conjunction with prioritization of need. Epilepsy measures help operationalize guidelines and practice parameters. Most epilepsy quality indicators are process-based metrics defined by delivering care to the patient. Systematic and reliable tracking and documentation of seizure frequency using consistent language is required as a patient-reported outcome within individuals over time and across populations. Emerging literature has demonstrated gaps in epilepsy care, perhaps highlighting limitations in the dissemination and implementation of guidelines and quality measures in clinical practice. Quality improvement methods applied to clinical data registries and learning health systems may afford new opportunities to iteratively, collaboratively, and feasibly disseminate guidelines and quality measures, measure epilepsy care quality, allow for the testing of interventions to mitigate identified care gaps, and, ultimately, improve care for patients with epilepsy.

A Multicenter Retrospective Observational Cohort Study of Seizure Freedom before Lennox-Gastaut Syndrome (the "Gap"). Opportunities for Prevention

Objective

Lennox-Gastaut Syndrome (LGS) is a severe, often treatment-resistant epilepsy syndrome typically diagnosed in early childhood. Many have seizures before diagnosis. Some have periods of seizure freedom before treatment resistance, i.e., a "gap." Review of these gaps may identify early candidate biomarkers of LGS and/or highlight opportunities for intervention.

Methods

We reviewed charts of children diagnosed with LGS born in 2008-2010 and diagnosed with LGS by 2014 at five academic medical centers in New York City using the RENYC (Rare Epilepsies in New York City) database. We collected dates of events of potential biomarkers by chart abstraction, including onset of slow spike-and-wave (SSW) and onset and offset of seizure freedom. Seizure-free periods ("gaps") were defined as greater than 30 days without unprovoked seizures.

Results

Thirty-three children had LGS (52% male; etiology 33% structural-acquired, 6% structural-congenital, 3% genetic-structural, 24% genetic, 33% unknown). Twenty-two (67%) had a gap before diagnosis. Eight of these twenty-two (36%) had SSW described before the gap, five (23%) during the gap, and six (27%) after the gap. A history of infantile epileptic spasms syndrome (IESS), age at seizure onset, and age of tonic seizure onset were not different between those with and without a gap. Of 20 (61%) with a history of IESS, 10 (30% of the full cohort) had not received recommended therapy (i.e., ACTH, prednisolone, or vigabatrin) as first-line treatment.

Conclusions

The appearance of SSW, even in seizure-free children, may herald the development of LGS in high-risk children. Further studies on its predictive value are warranted. Our findings also highlight use of recommended first-line therapy for infantile spasms as a potentially modifiable treatment gap in children who subsequently develop LGS.

Implementing American Academy of Neurology Quality Measures in Antigua Using Quality Improvement Methodology

Background and Objectives

The American Academy of Neurology has developed quality measures related to various neurologic disorders. A gap exists in the implementation of these measures in the different health care systems. To date, there has been no electronic health care record nor implementation of quality measures in Antigua. Therefore, we aimed to increase the percent of patients who have epilepsy quality measures documented using standardized common data elements in the outpatient neurology clinic at Sir Lester Bird Medical Center from 0% to 80% per week by June 1, 2022 and sustain for 6 months.

Methods

We used the Institute for Health care Improvement Model for Improvement methodology. A data use agreement was implemented. Data were displayed using statistical process control charts and the American Society for Quality criteria to determine statistical significance and centerline shifts.

Results

Current and future state process maps were developed to determine areas of opportunity for interventions. Interventions were developed following a "Plan-Do-Study-Act cycle." One intervention was the creation of a RedCap survey and database to be used by health care providers during clinical patient encounters. Because of multiple interventions, we achieved a 100% utilization of the survey for clinical care.

Discussion

Quality improvement (QI) methodology can be used for implementation of quality measures in various settings to improve patient care outcomes without use of significant resources. Implementation of quality measures can increase efficiency in clinical delivery. Similar QI methodology could be implemented in other resource-limited countries of the Caribbean and globally.

Improving Seizure Frequency Documentation and Classification

Background and Objectives

Accurate and reliable seizure data are essential for evaluating treatment strategies and tracking the quality of care in epilepsy clinics. This quality improvement project aimed to increase seizure documentation (i.e., documentation of seizure frequency from 80% to 100%, date of last seizure from 35% to 50%, and International League Against Epilepsy (ILAE) seizure classification from 35% to at least 50%) over 6 months.

Methods

We surveyed 7 epileptologists to determine their perceived seizure frequency, ILAE classification, and date of last seizure documentation habits. Baseline data were collected weekly from September to December 2021. Subsequently, we implemented a newly created flowsheet in our Electronic Health Record (EHR) based on the Epilepsy Learning Healthcare System (ELHS) Case Report Forms to increase seizure documentation in a standardized way. Two epileptologists tested this flowsheet tool in their epilepsy clinics between February 2022 and July 2022. Data were collected weekly and compared with documentation from other epileptologists within the same group.

Results

Epileptologists at our center believed they documented seizure frequency for 84%-87% of clinic visits, which aligned with baseline data collection, showing they recorded seizure frequency for 83% of clinic visits. Epileptologists believed they documented ILAE classification for 47%-52% of clinic visits, and baseline data showed this was documented in 33% of clinic visits. They also reported documenting the date of the last seizure for 52%-63% of clinic visits, but this occurred in only 35% of clinic visits. After implementing the new flowsheet, documentation increased to nearly 100% for all fields being completed by the providers who tested the flowsheet.

Discussion

We demonstrated that by implementing an easy-to-use standardized EHR documentation tool, our documentation of critical metrics, as defined by the ELHS, improved dramatically. This shows that simple and practical interventions can substantially improve clinically meaningful documentation.

Patient feedback and evaluation measures of a physical activity initiative: Exercise is Medicine program

BACKGROUND

Nearly half of American adults fail to meet national guidelines for physical activity (PA). As a major contributor to the development of preventable chronic diseases, insufficient PA is an important target for health behaviour interventions. Exercise is Medicine (EIM) aims to increase PA levels among primary care patients through routine PA evaluation, prescription, brief counselling, and referral to community resources. PA is treated as a vital sign with the goal of increasing PA levels in prescribed manageable doses. EIM is currently being implemented in UC San Diego Health System's primary care clinics.

OBJECTIVE

(i) To collect and summarize patient perceptions of EIM and its components. (ii) To identify discrepancies between patient-reported feedback and primary care provider (PCP) documentation in corresponding visit notes in the electronic medical record (EMR).

METHODS

Patient recall of EIM components was measured using a 10-item survey distributed via MyChart. PCP documentation of EIM was tracked in the EMR system.

RESULTS

Patient feedback (n = 316) about EIM components was positive and reinforced patients' confidence in their ability to increase PA. Approximately 70% of patients reported having a PA discussion with their PCP at their most recent visit, but only approximately 21% of these discussions were documented by PCPs using the preprogrammed smartphrase in the EMR.

CONCLUSION

Overall, patients reported positive perceptions of EIM. While patient perceptions of EIM suggested that PA discussions with PCPs are happening during the majority of visits, PCP documentation fell behind. Documentation via smartphrase may need to be modified for physicians to use.

The impact of medical scribes on emergency physician diagnostic testing and diagnosis charting

OBJECTIVES

Since the widespread adoption of electronic medical records (EMRs), medical scribes have been increasingly utilized in emergency department (ED) settings to offload the documentation burden of emergency physicians (EPs). Scribes have been shown to increase EP productivity and satisfaction; however, little is known about their effects on the EP's diagnostic process. We aimed to assess what effect, if any, scribes have on EP diagnostic test ordering and their documentation of differential diagnoses.

METHODS

We conducted a retrospective cohort study utilizing a chart review to compare diagnostic practices of EPs working both with and without scribes. We analyzed the number of laboratory and radiologic diagnostic studies ordered per encounter as well as characteristics of differential diagnosis documentation.

RESULTS

Scribes did not affect laboratory studies ordered per encounter (mean 6.31 by scribes vs. 7.35 by EPs, difference -1.04; 95% confidence interval [CI] -2.34 to 0.26) or radiologic studies ordered per encounter (mean 1.49 by scribes vs. 1.39 by EPs, difference 0.10; 95% CI -0.15 to 0.35). Scribes did not affect the frequency of documenting a differential diagnosis or the number of diagnoses considered in each differential, but they were associated with higher word counts in EP differentials (mean 72.29 by scribes vs. 50.00 by EPs, mean difference 22.79; 95% CI 6.77 to 38.81).

CONCLUSIONS

Scribe use does not appear to affect EP diagnostic test ordering but may have a small effect on their documentation of differential diagnoses.

Impact of intellectual and developmental disability on quality-of-life priorities in adults with epilepsy

OBJECTIVE

Adults living with intellectual and developmental disability (IDD) and epilepsy (IDD-E) face challenges in addition to those faced by the general population of adults with epilepsy, which may be associated with distinct priorities for improving health-related quality of life (HR-QOL). This study sought to (1) conduct a survey of HR-QOL priorities identified by adults with IDD-E and caregivers, and (2) perform an exploratory cross-sectional comparison to adults with epilepsy who do not have IDD.

METHODS

This cross-sectional study recruited 65 adults with IDD-E and 134 adults with epilepsy without IDD and caregivers. Using a three-step development process, 256 items from existing quality-of-life scales recommended by the American Academy of Neurology (AAN) were rated by patients/caregivers for their importance as HR-QOL priorities. HR-QOL items identified as critical to the majority of the sample of adults with IDD-E were reported. Health-related quality of life priorities were compared between adults with IDD-E and adults with epilepsy without IDD.

RESULTS

Health-related quality of life was significantly lower in adults with IDD-E. Health-related quality of life domains identified as critical priorities by adults with IDD-E included seizure burden, anti-seizure medication side effects, seizure unpredictability, and family impact. Priorities for improving HR-QOL differed between adults with and without IDD-E, with concerns about family impact, difficulty finding appropriate living conditions, inadequate assistance, and difficulty transitioning from pediatric-to-adult care valued significantly more among those with IDD-E.

SIGNIFICANCE

Intellectual and developmental disability is an important determinant of HR-QOL among adults with epilepsy. We report HR-QOL priorities identified by adults with IDD-E and their caregivers. These results may help epilepsy clinicians and researchers develop tailored strategies to address priorities of the patient with IDD-E/caregiver community.

Telemedicine Can Support Measurable and High-Quality Epilepsy Care During the COVID-19 Pandemic

Routine outpatient epilepsy care has shifted from in-person to telemedicine visits in response to safety concerns posed by the coronavirus disease 2019 (COVID-19) pandemic. But whether telemedicine can support and maintain standardized documentation of high-quality epilepsy care remains unknown. In response, the authors conducted a quality improvement study at a level 4 epilepsy center between January 20, 2019, and May 31, 2020. Weekly average completion proportion of standardized documentation used by a team of neurologists for adult patients for the diagnosis of epilepsy, seizure classification, and frequency were analyzed. By December 15, 2019, a 94% average weekly completion proportion of standardized epilepsy care documentation was achieved that was maintained through May 31, 2020. Moreover, during the period of predominately telemedicine encounters in response to the pandemic, the completion proportion was 90%. This study indicates that high completion of standardized documentation of seizure-related information can be sustained during telemedicine appointments for routine outpatient epilepsy care at a level 4 epilepsy center.

Ambulatory care for epilepsy via telemedicine during the COVID-19 pandemic

OBJECTIVE

To assess feasibility, patient satisfaction, and financial advantages of telemedicine for epilepsy ambulatory care during the current COVID-19 pandemic.

METHODS

The demographic and clinical characteristics of all consecutive patients evaluated via telemedicine at a level 4 epilepsy center between March 20 and April 20, 2020 were obtained retrospectively from electronic medical records. A telephone survey to assess patient satisfaction and preferences was conducted within one month following the initial visit.

RESULTS

Among 223 telehealth patients, 85.7% used both synchronous audio and video technology. During the visits, 39% of patients had their anticonvulsants adjusted while 18.8% and 11.2% were referred to laboratory/diagnostic testing and specialty consults, respectively. In a post-visit survey, the highest degree of satisfaction with care was expressed by 76.9% of patients. The degree of satisfaction tended to increase the further a patient lived from the clinic (p = 0.05). Beyond the pandemic, 89% of patients reported a preference for continuing telemedicine if their epilepsy symptoms remained stable, while only 44.4% chose telemedicine should their symptoms worsen. Inclement weather and lack of transportation were factors favoring continued use of telemedicine. An estimated cost saving to patient attributed to telemedicine was $30.20 ± 3.8 per visit.

SIGNIFICANCE

Our findings suggest that epilepsy care via telemedicine provided high satisfaction and economic benefit, without compromising patients' quality of care, thereby supporting the use of virtual care during current and future epidemiological fallouts. Beyond the current pandemic, patients with stable seizure symptoms may prefer to use telemedicine for their epilepsy care.