RE White, Albuquerque VA; D Gray, Albuquerque VA; BJ Skipper, University of New Mexico

Objectives: Nursing staff in VA primary care clinics are required to document numerous patient education and screening activities, and they are using progressively more advanced software in the electronic patient record to accomplish this documentation. However, time limitations make it difficult to accomplish all these educational and screening mandates while the patient is in clinic, and staff may miss documenting activities which were previous accomplished but not quickly found in the record. During the summer of 2000, we decided to experiment with how this process occurred for patients taught the proper use of metered dose inhalers (MDIs). We chose to update our electronic documentation of this activity (1) at a time other than the patient visit and (2) by using a population based approach.

Methods: At our facility, two teams of similar provider and support staff composition provide primary care in non-teaching clinics. Of the 6129 patients in group practice A, 640 use MDIs, and 572 of 5596 group practice B patients use MDIs. Information about this population of MDIs users was compiled, and their names and telephone numbers were listed in the chronological order of their next appointment. Starting in May 2000, clerks began calling each patient as their next appointment approached, in order to remind patients to obtain MDI instruction when they attended clinic. In group practice B, nurses also used the list during lulls in routine clinic screening activities to contact patients and update the electronic record. Five months later, electronic documentation of MDI patient education was extracted from the computer patient database. Documentation data was also obtained about two education/screening activities not targeted in this study (depression screening and patient education about exercise) because these activities apply to all group practice patients and are electronically documented in the same manner as MDI teaching.

Results: In group practice B, MDI inhaler education, depression screening and exercise education were documented on 84%, 60% and 82% of the 572 MDI patients. In group practice A, the same percentages were 52%, 65% and 50% of their 640 MDI patients. Chi square comparisons were made of patients receiving only MDI instruction or MDI teaching and depression screening or all three education/screening activities. In each circumstance group practice B performance was significantly (p<.05) higher. Logistic regression also showed that group practice B was associated with a higher likelihood of MDI teaching documentation (odds ratio 3.54, p<.001).

Conclusions: Documentation of a specific educational task was better accomplished when a population of patients was targeted for review at times when those patients were not actually in clinic for visits.

Impact: To achieve optimal outcomes in chronic disease nurses and doctors must follow numerous guidelines. Teaching patients the proper use of metered dose inhalers (MDI) is one such guideline. However, accomplishing this along with many other guidelines during each routine clinic visits is challenging because of time and other patient and practitioner concerns. Documentation may be better accomplished when a population of patients is targeted for review at times when they are not actually in clinic.