Abstracts

Rationale: Practice guidelines for the evaluation of a first seizure or new-onset epilepsy include evaluation with EEG and counseling regarding seizure precautions and safety measures. The Comprehensive Epilepsy Center and Children's Medical Center Dallas requires primary care providers (PCPs) to send medical records with each referral of a child for evaluation of new onset seizures or epilepsy. PCP notes were analyzed to determine the frequency with which diagnostic testing was ordered, whether safety counseling was provided, and completeness of the history recorded.Methods: 226 PCP notes documenting seizures or epilepsy as a reason for referral to the UT Southwestern Medical Center/ Children s Medical Center were reviewed. 49 notes were handwritten; 177 notes were from electronic medical records. The notes were analyzed for 5 items related to completeness (including seizures in the history, a medication list, a review of systems, a neurological exam, and plan to refer to neurology). In addition, we evaluated whether additional diagnostic testing was ordered, whether safety teaching was provided and patient insurance status.Results: 35% of PCPs documented a plan to order EEG as part of the initial seizure evaluation, but only 17% included seizure safety teaching in their notes. 12% of PCPs planned to order neuroimaging. Electronic medical records tended to be more complete than written notes, with 75% of electronic notes including at least 4 of 5 items, compared to 47% of written notes (p .01). However, electronic PCP notes were more likely than written PCP notes to incorrectly indicate no seizures in the review of systems (12% vs. 0%, p .01). While 98% of written PCP notes included seizure in the History of Present Illness section, only 87% of electronic PCP notes did the same (p .01). Patients with commercial insurance were more likely than those without to have electronic medical records (94% vs. 76%, p .01). However, there were no significant correlations between insurance status and safety counseling, EEG ordered or CT/MRI ordered. There were no significant differences between electronic and written PCP notes in tests ordered, safety counseling, medications listed and inclusion of detailed descriptions of seizures.Conclusions: Pediatricians are doing a better job at ordering testing than providing safety counseling to patients with new onset seizures. Although private insurance did not impact effectiveness of patient care, it did impact utilization of electronic medical records. PCPs that used electronic records tended to have more complete notes, but sometimes sacrificed accuracy in review of systems and HPI. Electronic PCP notes were not more likely to have useful information such as medication list or detailed description of seizures. Our results suggest that PCPs might benefit from better access to resources for seizure safety education, perhaps incorporated into the electronic medical record. Current PCP use of the electronic medical record results in more complete notes but no advantage in patient evaluation or care.