Prospective, randomized trial of template-assisted versus undirected written recording of physician records in the emergency department

Study objective: To determine whether use of the T-System (Emergency Servic es Consultants, Irving, TX) template-generated medical documentation system (1) decreases physician evaluation time in the emergency department, (2) i ncreases gross billing under the 1997 Health Care Financing Administration guidelines by minimizing downcoding caused by inadequate documentation, and (3) increases physician satisfaction with the documentation process, compa red with the undirected written narrative format. Methods: A prospective, randomized, unblinded, controlled, convenience tria l of documentation with the T-System of ED templates versus undirected writ ten documentation was conducted in the ED of a county-owned, university-aff iliated hospital. All patients seen between the hours of 7 AM and 10 PM dur ing a 16-day period were included. The intervention was varying the method of documentation of the emergency physician. Adequacy of randomization to t he 2 documentation groups was assessed by comparing ED triage classificatio n, patient disposition, level of training of the evaluating physician, and whether ED consultation with other services occurred. Outcome measurements included emergency physician total evaluation and treatment time, professio nal bill, and satisfaction, as evaluated by a questionnaire completed after the study period. The 2 documentation groups were compared by an intention -to-treat analysis and by Student's t test and the median test as appropria te. Results: A total of 1,228 patient encounters were included. Emergency physi cian total evaluation and treatment time with template-directed documentati on was 4.6 minutes less than with undirected recording, a difference that w as not significant (95% confidence interval [CI], -9.2 to 18.3). Gross bill ing was $29.60 more per patient (95% CI, $22.20 to $37.00) with the T-Syste m, as assessed by our hospital coders. This difference was caused by a mean .50 (95% Cl, .39 to .60) higher level of evaluation and management coding. Physicians preferred the T-System (P<.0005). Conclusion: Use of template-assisted documentation in the ED was associated with higher gross billing and physician satisfaction but no significant de crease in emergency physician total evaluation time.