The effect of standardized, computer-guided templates on quality of VA disability exams.

BACKGROUND: The costs and limitations of clinical encounter documentation using dictation/transcription have provided impetus for increased use of computerized structured data entry to enforce standardization and improve quality. The purpose of the present study is to compare exam report quality of Veterans Affairs (VA) disability exams documented by computerized protocol-guided templates with exams documented in the usual fashion (dictation). METHODS: Exam report quality for 17,490 VA compensation and pension (C&P) disability exams reviewed in 2005 was compared for exam reports completed by template and exam reports completed in routine fashion (dictation). An additional set of 2,903 exams reviewed for quality the last three months of 2004 were used for baseline comparison. RESULTS: Mean template quality scores of 91 (95% CI 89, 92) showed significant improvement over routine exams conducted during the study period 78 (95% CI 77, 78) and at baseline 73 (95% CI 72, 75). The quality difference among examination types is presented. DISCUSSION: The results of the present study suggest that use of the standardized, guided documentation templates in VA disability exams produces significant improvement in quality compared with routinely completed exams (dictation). The templates demonstrate the opportunity and capacity for informatics tools to enhance delivery of care when operating in a health system with a sophisticated electronic medical record.

SNOMED CT: utility for a general medical evaluation template.

BACKGROUND: The U.S. government has licensed SNOMED CT to permit broad-based evaluation and use of the terminology. We evaluated the ability of SNOMED CT to represent terms used for interface objects (e.g., labels and captions) and concepts used for data and branching logic in a general medical evaluation template in use within the Department of Veterans Affairs. METHODS: The general medical evaluation form definition, report definition, and script files were parsed and 1573 expressions were mapped into SNOMED CT. Compositional expressions required to represent 1171 concepts. Double independent reviews were conducted. Exact concept level matches were used to evaluate reference coverage. Exact term level matches were required for interface terms. Semantics were analyzed for a randomly selected subset of 20 terms. RESULTS: Sensitivity of SNOMED CT as a reference terminology was 63.8% , ranging from 29.3% for history items to 92.4% for exam items. SNOMED CT's sensitivity as an "interface terminology" was 55.0%. 80% of the necessary linking semantics for the subset were present. Subgroup statistics are presented. DISCUSSION: SNOMED CT is promising as a terminology for knowledge representation underlying a large general medical evaluation. Its performed less well as an interface terminology.