Electronic Health Record Documentation of Headache Presentation: Argument for Improvement in an Integrated Healthcare System in Order to Better Treatment
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Key messages
- This study had the aim of understanding the degree to which components of headache history, including International Classification of Headache Disorders (ICHD)-3 symptomatology, prior treatments offered and provided, degree of disability and impact on quality of life are documented in the EHR by health care providers caring for Veterans with headache.
- Low documentation rates for essential elements of the headache history, including headache features were found, which guide providers in making an accurate headache diagnosis; this highlights the need for more specific documentation in the EHR for headache diagnoses.
- We propose the use of a Structured Diagnostic Interview for Headache to aid in the accurate diagnosis of headache disorders, as well as more education among primary care regarding headache.
Presenting Author
Jason J. Sico, MD, MHS
Associate Professor of Neurology & Director of VA Headache Center of Excellence (HCoE) Research and Evaluation Center
VA Connecticut Healthcare System
West Haven, Connecticut
Jason J. Sico, MD, MHS is an Associate Professor of Neurology and Internal Medicine (General Medicine) at Yale School of Medicine and serves as the Director of the Veterans Health Administration Headache Center of Excellence (HCoE) Research and Evaluation Center and the VA Connecticut Healthcare System-based HCoE. Dr. Sico is neurologist with UCNS-Headache Medicine certification, internist, and health services researcher who delivers both clinical care and conducts research intended to improve care quality and delivery to Veterans with headache.
Author disclosures
Jason J. Sico, MD, MHS: I do not have any relevant financial / non-financial relationships with any proprietary interests.
