Health Care Quality

Embedding clinical guidelines in a computer charting system doesn't always improve care

Doctors disagree about the best way to treat young children with a high fever (38 degrees C or higher) of unknown source. David L. Schriger, M.D., M.P.H., and colleagues at the University of California, Los Angeles, embedded clinical guidelines for managing these and other febrile children in the university hospital's computerized Emergency Department Expert Charting System (EDECS). In a study supported in part by the Agency for Healthcare Research and Quality (HS06284), they examined the impact of this approach on the care of 830 febrile children under the age of 3 years seen in the hospital's emergency department (ED).

The researchers found that although EDECS improved documentation of care, there was no consistent measurable impact on quality of care or medical charges for these children. Once the physician entered the relevant medical history and physical data, the program provided suggestions regarding the appropriateness of various diagnostic tests and treatment. When the physician selected the "Rationale" button, the reasoning for each recommendation was displayed. When he or she deviated from a recommendation, EDECS requested an explanation. Once initial testing and treatment were completed, EDECS provided further advice about the need for additional testing and treatment, reevaluation and disposition of the patient, and after-care instructions for patients sent home. Use of the EDECS increased physicians' mean documentation of 21 essential history and physical examination items from 80 percent when they had used handwritten charts to 92 percent and increased mean documentation of 10 after-care items from 48 percent to 81 percent. However, there was no demonstrable improvement or worsening in appropriateness of care and no change in hospital charges for these children.

These findings contrast sharply with improved care and reduced charges that resulted from similar software designed to manage occupational exposures to potentially infectious blood and body fluids in health care workers. The authors suggest that the controversy surrounding treatment of children with fever of unknown source may have hampered the willingness of doctors to follow the EDECS guidelines and the small number of children with fever without source in the sample may have limited their ability to demonstrate changes that did occur.

For more details, see "Implementation of clinical guidelines via a computer charting system: Effect on the care of febrile children less than three years of age," by Dr. Schriger, Larry J. Baraff, M.D., Kelly Buller, M.D., M.P.H., and others, in the March 2000 Journal of the American Medical Informatics Association 7(2), pp. 186-195.

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