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 Services Consultants, Irving, TX) template-generated medical documentation system (1) decreases physician evaluation time in the emergency department, (2) increases 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, compared with the undirected written narrative format. Methods: A prospective, randomized, unblinded, controlled, convenience trial of documentation with the T-System of ED templates versus undirected written documentation was conducted in the ED of a county-owned, university-affiliated hospital. All patients seen between the hours of 7 AM and 10 PM during a 16-day period were included. The intervention was varying the method of documentation of the emergency physician. Adequacy of randomization to the 2 documentation groups was assessed by comparing ED triage classification, 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, professional 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 appropriate. Results: A total of 1,228 patient encounters were included. Emergency physician total evaluation and treatment time with template-directed documentation was 4.6 minutes less than with undirected recording, a difference that was not significant (95% confidence interval [CI], -9.2 to 18.3). Gross billing was $29.60 more per patient (95% CI, $22.20 to $37.00) with the T-System, 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 decrease in emergency physician total evaluation time.