Implementation of clinical guidelines via a computer charting system: Effect on the care of febrile children less than three years of age

Objective: The authors have shown that clinical guidelines embedded in an e lectronic medical record improved the quality, while lowering the cost, of care for health care workers who incurred occupational exposures to body fl uid. They seek to determine whether this system has similar effects on the emergency department care of young children with febrile illness. Design: Off;on-off, interrupted time series with intent-to-treat analysis. Setting: University hospital emergency department. Subjects: 830 febrile children less than 3 years of age and the physicians who treated them. Interventions: Implementation of an electronic medical record that provides real-time advice regarding the content of the history and physical examina tion and recommendations regarding laboratory testing, treatment, diagnosis , and disposition. Measurements: Documentation of essential items in the medical record and af ter-care instructions; compliance with guidelines regarding testing, treatm ent, and diagnosis; charges. Results: The computer was used in 64 percent of eligible cases. Mean percen tage documentation of 21 essential history and physical examination items i ncreased from 80 percent during the baseline period to 92 percent in the in tervention phase (13 percent increase; 95 percent CI, 10-15 percent). Mean percentage documentation of ten items in the after-care instructions increa sed from 48 percent at baseline to 81 percent during the intervention phase (33 percent increase; 95 percent confidence interval, 28-38 percent). All documentation decreased to baseline when the computer system was removed. T here were no demonstrable improvements in appropriateness of care, nor was there evidence that appropriateness worsened. Mean charges were not changed by the intervention. Conclusion: The intervention markedly improved documentation, had little ef fect on the appropriateness of the process of care, and had no effect on ch arges. Results for the febrile child module differ from those for the modul e for occupational blood and body fluid exposure (a more focused and straig htforward medical condition), underscoring the need for implementation meth ods to be tailored to specific clinical complaints.