A Pilot Trial of a Computerized Renal Template Note to Improve Resident Knowledge and Documentation of Kidney Disease

Summary

Background: Kidney disease is under-documented in physician notes. The use of template-guided notes may improve physician recognition of kidney disease early in training.

Objective: The objective of this study was to determine whether a computerized inpatient renal template note with clinical decision support improves resident knowledge and documentation of kidney disease.

Methods: In this prospective study, first year medical residents were encouraged to use the renal template note for documentation over a one-month period. The renal template note included an option for classification of acute kidney injury (AKI) and chronic kidney disease (CKD) categories with a link to standard classifications. Pre- and post-knowledge of AKI and CKD categories was tested with a quiz and surveys of resident experience with the intervention were conducted. Appropriate AKI and/or CKD classification was determined in 100 renal template notes and 112 comparable historical internal medicine resident progress notes from approximately one year prior.

Results: 2,435 inpatient encounters amongst 15 residents who participated were documented using the renal template note. A significantly higher percent of residents correctly staged earlier stage CKD (CKD3) using the renal template note compared to historical notes (9/46 vs. 0/33, p<0.01). Documentation of AKI and more advanced CKD stages (CKD4 and 5) did not improve. Knowledge based on quiz scores increased modestly but was not significant. The renal template note was well received by residents and was perceived as helping improve knowledge and documentation of kidney disease.

Conclusions: The renal template note significantly improved staging of earlier stage CKD (CKD3) with a modest but non-significant improvement in resident knowledge. Given the importance of early recognition and treatment of CKD, future studies should focus on teaching early recognition using template notes with supplemental educational interventions.

Citation: Shirazian S, Wang R, Moledina D, Liberman V, Zeidan J, Strand D, Mattana J. A pilot trial of a computerized renal template note to improve resident knowledge and documentation of kidney disease. Appl Clin Inf 2013; 4: 528–540

http://dx.doi.org/10.4338/ACI-2013-07-RA-0048

Keywords

Clinical decision support systems - kidney disease - medical education - electronic medical records - templates

• References

• 1 Collins AJ, Foley RN, Chavers B, Gilbertson D, Herzog C, Johansen K, Kasiske B, Kutner N, Liu J, St Peter W, Guo H, Gustafson S, Heubner B, Lamb K, Li S, Peng Y, Qiu Y, Roberts T, Skeans M, Snyder J, Solid C, Thompson B, Wang C, Weinhandl E, Zaun D, Arko C, Chen SC, Daniels F, Ebben J, Frazier E, Hanzlik C, Johnson R, Sheets D, Wang X, Forrest B, Constantini E, Everson S, Eggers P, Agodoa L. ’United States Renal Data System 2011 Annual Data Report: Atlas of chronic kidney disease & end-stage renal disease in the United States. Am J Kidney Dis 2012; 59 1 Suppl 1 A7 e1-420.
• 2 Kinchen KS, Sadler J, Fink N, Brookmeyer R, Klag MJ, Levey AS, Powe NR. The timing of specialist evaluation in chronic kidney disease and mortality. Ann Intern Med 2002; 137 (06) 479-486.
• 3 Levinsky NG. Specialist evaluation in chronic kidney disease: too little, too late. Ann Intern Med 2002; Sep 137 (Suppl. 06) 542-543.
• 4 Rothberg MB, Kehoe ED, Courtemanche AL, Kenosi T, Pekow PS, Brennan MJ, Mulhern JG, Braden GL. Recognition and management of chronic kidney disease in an elderly ambulatory population. J Gen Intern Med 2008; 23 (08) 1125-1130.
• 5 Chase HS, Radhakrishnan J, Shirazian S, Rao MK, Vawdrey DK. Under-documentation of chronic kidney disease in the electronic health record in outpatients. J Am Med Inform Assoc 2010; 17 (05) 588-594.
• 6 Navaneethan SD, Kandula P, Jeevanantham V, Nally Jr. JV, Liebman SE. Referral patterns of primary care physicians for chronic kidney disease in general population and geriatric patients. Clin Nephrol 2010; 73 (04) 260-267.
• 7 Plantinga LC, Boulware LE, Coresh J, Stevens LA, Miller ER, 3rd, Saran R, Messer KL, Levey AS, Powe NR. Patient awareness of chronic kidney disease: trends and predictors. Arch Intern Med 2008; 168 (020) 2268-2275.
• 8 Fox CH, Swanson A, Kahn LS, Glaser K, Murray BM. Improving chronic kidney disease care in primary care practices: an upstate New York practice-based research network (UNYNET) study. J Am Board Fam Med 2008; 21 (06) 522-530.
• 9 Patel TG, Pogach LM, Barth RH. CKD screening and management in the Veterans Health Administration: the impact of system organization and an innovative electronic record. Am J Kidney Dis 2009; 53 (3 Suppl 3) S78-S85.
• 10 Litvin CB, Davis KS, Moran WP, Iverson PJ, Zhao Y, Zapka J. The use of clinical decision-support tools to facilitate geriatric education. J Am Geriatr Soc 2012; 60 (06) 1145-1149.
• 11 Riggio JM, Sorokin R, Moxey ED, Mather P, Gould S, Kane GC. Effectiveness of a clinical-decision-support system in improving compliance with cardiac-care quality measures and supporting resident training. Acad Med 2009; 84 (012) 1719-1726.
• 12 Keenan CR, Nguyen HH, Srinivasan M. Electronic medical records and their impact on resident and medical student education. Acad Psychiatry 2006; 30 (06) 522-527.
• 13 Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P. Acute renal failure –definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 2004; 8 (04) R204-R212.
• 14 Stevens PE, Levin A. Evaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline. Ann Intern Med 2013; 158 (011) 825-830.
• 15 Lewington AJ, Cerda J, Mehta RL. Raising awareness of acute kidney injury: a global perspective of a silent killer. Kidney Int; 2013. May 1.
• 16 Fox CH, Brooks A, Zayas LE, McClellan W, Murray B. Primary care physicians’ knowledge and practice patterns in the treatment of chronic kidney disease: an Upstate New York Practice-based Research Network (UNYNET) study. J Am Board Fam Med 2006; 19 (01) 54-61.
• 17 Marill KA, Gauharou ES, Nelson BK, Peterson MA, Curtis RL, Gonzalez MR. Prospective, randomized trial of template-assisted versus undirected written recording of physician records in the emergency department. Ann Emerg Med 1999; 33 (05) 500-509.
• 18 Mulvehill S, Schneider G, Cullen CM, Roaten S, Foster B, Porter A. Template-guided versus undirected written medical documentation: a prospective, randomized trial in a family medicine residency clinic. J Am Board Fam Pract 2005; 18 (06) 464-469.
• 19 Ferris M, Shoham DA, Pierre-Louis M, Mandhelker L, Detwiler RK, Kshirsagar AV. High prevalence of unlabeled chronic kidney disease among inpatients at a tertiary-care hospital. Am J Med Sci 2009; 337 (02) 93-97.
• 20 Stack AG. Impact of timing of nephrology referral and pre-ESRD care on mortality risk among new ESRD patients in the United States. Am J Kidney Dis 2003; 41 (02) 310-318.
• 21 Grams ME, Plantinga LC, Hedgeman E, Saran R, Myers GL, Williams DE, Powe NR. Validation of CKD and related conditions in existing data sets: A systematic review. Am J Kidney Dis 2011; 57 (01) 44-54.