Abstracts

Rationale: Epileptologists often get referrals that have them puzzled and disturbed – those patients have been managed in ways that appear chaotic and illogical (too many medications at once, unnecessary studies, or lack of a proper evaluation). We attempted to evaluate the extent of this problem, and to develop a Care Pathway for internists and family physicians who encounter patients with seizures and epilepsy.Methods: Two directors of Community Clinics, a University-based Epileptologist, and a Neuromonitoring manager teamed up for this project of over 2 years. The project had a three-phase design: 1. Information collection, by retrospective automated query of outpatient EMR with exit ICD codes corresponding to seizures and epilepsy 2. Identification of specific areas of concern in diagnosis, treatment and followup by retrospective analysis of patient records 3. Development and implementation of an Epilepsy Care Pathway (ECP) for the use of general internal medicine and family medicine physiciansResults: ICD-9 codes 345 and 780 were quieried, and over 8,000 records were retrieved for the period of 12 months. The query was then restricted to code 345 only, which meant that the provider was sure of the diagnosis of epilepsy upon completion of new patient or followup visit. Methodological problems lead to quick abandonment of the Phase 2 of the project, after a trial of analyzing 48 records. The questions asked for phase 2, such as - was history complete for seizure semiology, frequency, exacerbators, was imaging ordered with appropriate protocols, was an EEG obtained, were medication levels assessed and adverse effects addressed – were unanswerable from the review of outpatient visit notes. This was true for all notes chosen randomly and distributed among the project participants. The reasons for failure were hypothesized as: -insufficient appointment time, and thus skeletal, uninformative notes -lack of awareness of PCP of how to interview a patient with seizures -seizures/epilepsy not being the chief complaint, but the visit diagnosis remaining under that category -followups after ED or hospitalization - when necessary tests and imaging had been done elsewhere Therefore, the project was reduced to Phase 3, EMR-based pathways development and implementation. ECP was designed and implemented as a two-pronged algorithm (see Figures), and a related EMR ""smart"" order set, both incorporating the expertise of the epileptologist and generalists involved, and current AAN and AES recommendations, for the evaluation of a first-time seizure, and for follow-up, with suggestions for studies and specialty referrals.Conclusions: Epilepsy Care Pathway was conceived as a project in improving services to people with seizures and epilepsy in the state of Utah. We encountered unforeseable issues in assessing the depth of the existing problems - retrospective EMR review did not yield information as to the providers' thinking and decision-making. We thus proceeded to create and impelment an algorithm and a corresponding order set, which has been implemented in EPIC EMR, and ready for use. Outcomes will be assessed and hopefully reported here next year.