Over the past four decades, the number of youth participating in high school athletics has doubled from 4 million to 8 million per year (1,2). As youth participation in organized sports has increased, injuries among this population also have increased. Recent surveillance data have documented nearly 2 million high school athletic injuries each year (3,4).
Increasingly, certified athletic trainers (ATs) provide daily medical coverage of athletic activities at private and public high schools and community athletic leagues throughout the nation. In health care professions, timely and accessible electronic documentation of provider-patient encounters is increasingly being demanded. Often, ATs face barriers to documentation in the course of athletic care, including lack of time, lack of computers or typical tools available in an office, or perception of lack of need to document common and routine care, such as icing or taping (5). Timely and efficient documentation capabilities are important for ATs and sports medicine physicians to assist with continuity of care for athletes seen outside traditional clinics, who may not have medical records at local provider offices, as well as for legal purposes (6).
The sports medicine outreach program is an established connection between our institution and the community in which ATs, partnered with sports medicine physicians, provide medical coverage of youth athletic practices and competitions throughout Middle Tennessee. Prior to 2013, when youth athletes were injured during a practice or a game, the AT or physician who evaluated and treated the athlete on the sideline would document the injury and treatment with a traditional hand-written documentation system. This required physical transport of documented encounters from remote locations to the medical center, was not easily accessible to physicians who might subsequently follow up on injured athletes across various clinic locations, and did not facilitate electronic measurement of the type and nature of encounters. The ability to perform documentation using mobile device-based tools presents a potential solution.
In 2013, our athletic training team developed a Sports Medicine Outreach Athletic Injury Database (AID) utilizing the Research Electronic Database Capture (REDCap) technology to enable ATs and physicians to document sideline encounters with youth athletes using mobile devices at the time of the encounter. REDCap is a secure, Health Insurance Portability and Accountability Act-compliant (HIPAA) web application for creating and managing online surveys and databases (7). In July 2013, our institution's ATs and sports medicine physicians (sports medicine providers) started using mobile devices to document clinical encounters with athletes that occur outside of the medical center on the sidelines of athletic practices and competitions in the AID via REDCap. The purpose of this study was to describe the implementation of the AID as defined by three outcomes: sports medicine providers’ patterns of AID use, the nature of sideline athlete encounters captured through AID use, and sports medicine providers’ satisfaction with AID use.
Between July 2013 and June 2015, 53 ATs and 32 physicians affiliated with the sports medicine outreach program provided sideline coverage for 25 local public schools, three local private high schools, as well as several local youth sports leagues. The high school sports covered included baseball, basketball, bowling, cheerleading, football, golf, lacrosse, soccer, softball, swimming, tennis, track and field, ultimate frisbee, volleyball, wrestling, and cross-country. The youth sports leagues additionally included lacrosse, ultimate frisbee, and running clubs not affiliated with a particular school. ATs attended practices and local competitions for their assigned schools and provided sideline evaluation as well as ongoing management of sports-related injuries on a daily basis. The physicians included in the sports medicine outreach program are orthopedic, internal medicine, pediatrics, combined internal-medicine and pediatrics, and emergency medicine resident and faculty physicians. In general, physicians attended home football games only. While ATs and/or MDs do not provide exhaustive coverage for every practice and competition for the teams at the schools and leagues represented within the sport medicine outreach program between 2013 and 2015, a sports medicine provider trained in using the AID was on site for the majority of school-based practices and school and youth league competitions.
Vanderbilt Sports Medicine Outreach Athletic Injury Database
Development of the AID
In 2013, the athletic training team developed the AID utilizing Research Electronic Data Capture (REDCap) technology (7). REDCap is a secure, Web application for managing online databases. Through REDCap, the AID is HIPAA-compliant. The AID may be accessed via any mobile device with an Internet or cellular connection. The AID also may be accessed via desktop, laptop, or other Internet-enabled device.
Within the sports medicine outreach program, ATs and physicians complete an encounter report in REDCap for each unique encounter with injured youth athletes that occurs on the sidelines of athletic practices and competitions. ATs and physicians select between six different types of encounter reports within the AID: Injury Report, Physician Note, Daily Note, Contact Note, No-show Note, and Discharge Note. Within each type of note, providers input athletes’ demographic data, including age, sex, high school or youth league name, and sport, as well as clinical history, relevant medical history, physical examination, diagnosis, initial management, and referral recommendations. See Figure 1 for an abbreviated example of the AID user interface. While ATs and physicians have access to team rosters, this information is not uploaded into AID prior to any athlete encounters. Instead, each injured athlete voluntarily provides his or her own demographic information and medical history to the sports medicine provider at the point of contact, and the provider then inputs this information into the AID at the time of each encounter.
Each encounter with an athlete is entered into the AID as a separate record; encounters are not grouped or linked by injury. For example, an athlete, who has a single encounter with an AT for an ankle sprain in the fall and who suffers a quadriceps strain in the spring requiring three AT encounters, would have a total of four distinct records within the AID for that given school year. While AID users may access an encounter report for athletes seen for subsequent care, the AID does not include follow-up visits with physicians or ATs. Due to institutional preferences related to research endeavors regarding sports-related concussions, the AID excludes encounters with athletes sustaining sports-related concussions. A similar but separate system is utilized for documenting encounters in which athletes have sustained sports-related concussions and was excluded from this analysis.
While protected health information including the athlete’s name and age are collected by ATs and physicians and entered into the AID for use in coordinating clinical care, no protected health information was utilized when downloading the data for analysis. The AID does not contain Family Educational Rights and Privacy Act-protected information. This study was approved by Vanderbilt’s Institutional Review Board.
Training on AID Use
Physicians and ATs who provided coverage through the sports medicine outreach program received training on how to access and use the AID predominantly via a face-to-face meeting with sports medicine leadership and electronically communicated instructions. An e-mail with instructions and a link to the AID was emailed to the sports medicine providers, and users were able to save this link on their home screens as an application for efficient access and use. Providers were instructed to use smartphones, tablets, or other mobile devices to input data relevant to their athlete interactions at the time of their sideline encounters.
Study Design and Aims
We conducted a retrospective descriptive analysis of the implementation of the AID, a mobile device-based tool for documenting sideline encounters between athletes and sports medicine providers from July 2013 to June 2015. Our primary measures of the implementation process were 1) sports medicine providers’ patterns of AID use, 2) nature of sideline encounters captured through AID use, and 3) sports medicine providers’ satisfaction with AID use. Our primary aim was to describe the pattern of Sports Medicine providers’ AID use, as defined by the frequency and types of encounters (e.g., AT or physician encounter; school team or youth league team) between Sports Medicine providers and athletes. Our secondary aim was to describe the nature of sideline encounters captured through AID use, as defined by athlete age, sex, type of injury (e.g., sprain, abrasion), timing of injury (e.g., practice vs. game), anatomic body part injured, referral recommendations (e.g., no follow up, emergency department), and participation recommendations (e.g., restricted play, full return to play). Our third aim was to evaluate sports medicine providers' satisfaction with AID use, as defined by self-reported ease of use, frequency of use, and overall satisfaction with the AID compared with a traditional written documentation system. To evaluate AID user satisfaction, we conducted a cross-sectional evaluation among AT and physician AID users through a brief, anonymous survey administered at the conclusion of 2 yr of AID use.
The AID captured in REDCap was downloaded into Excel and then analyzed to provide information on patterns of use and nature of encounters. We used descriptive statistics including proportions, averages, and trends to analyze the patterns of AID use and the nature of sideline encounters captured through the AID. We also used descriptive statistics to report the outcomes of the satisfaction survey from ATs and physicians regarding their experiences with the AID. Microsoft Excel™ was utilized for all data analyses.
Sports Medicine Providers’ Patterns of AID Use
Over the course of 24 months, ATs and physicians documented 6237 athlete contacts, which is approximately 60 contacts per week. Ninety-nine percent of the contacts were by ATs and <1% were by physicians. The majority of contacts occurred at high school events (85%) as compared with youth sports leagues (15%). The three most commonly used types of notes were the contact note (40%), injury report (29%), and daily note (21%).
Nature of Sideline Encounters Captured through AID Use
The majority of encounters were with males (73%) (Table 1). Athletes' average age was 15.9 yr (SD, 2.7 yr). A total of 53% of injury contacts occurred in competitions versus at practices (47%). Most encounters occurred with athletes participating in football (51%), soccer (15%), and basketball (12%, Fig. 2). Contacts for knee (21%), ankle (21%), and shoulder (12%) injuries were most common. Approximately 42% of injured athletes were referred to return to their school AT for follow-up, and 54% of injured athletes were withheld from further activity at the time of their injury (Table 1).
Sports Medicine Providers’ Satisfaction with AID Use
A survey of Sports Medicine providers’ satisfaction with using the AID for documenting sidelines encounters with athletes was administered 2 yr after initial AID implementation. A total of 75% of ATs, and 25% of physicians responded (Table 2). Eighty-five percent of responders expressed overall satisfaction with using the AID to document sideline athlete contacts, and 76.6% of responders preferred using the AID to traditional hand-written documentation. A total of 72% of sports medicine providers reported that AID was not slower than a traditional written documentation system. On average, responding providers indicated that it took them approximately 3.75 min (+/− 3.14 min) to fill out an initial Injury Report in the AID.
As youth participation in sport has increased, health care providers for athletes, including ATs and sports medicine physicians, are increasingly compelled to document sideline encounters with athletes in a timely, efficient, affordable, electronically accessible, HIPAA-compliant, and legal method. The ability to perform documentation using mobile device-based tools presents a potential solution. Our study highlights the potential benefits of sideline electronic documentation for managing athlete encounters that do not occur in traditional office settings. Through use of REDCap, a widely available Web application, documentation systems similar to the AID can be developed by other sports medicine outreach programs.
Our study reports the process of implementing the AID, a mobile device-based technology to document sideline encounters with athletes and evaluates 1) sports medicine providers' patterns of AID use, 2) the nature of sideline athlete encounters captured through AID use, and 3) sports medicine providers' satisfaction with AID use. The 6327 athlete encounters documented in the AID indicate that it is well used. However, there is no prior institutional data for comparison.
There is currently a paucity of literature regarding the use of mobile device-based technology for the purpose of documenting sideline encounters between Sports Medicine providers and injured athletes. Other databases have been developed for cataloging sports-related injuries among high school, collegiate, and professional athletes, including the NCAA Injury Surveillance Program (ISP) and the National High School Sports-Related Injury Surveillance Reporting Information Online (RIO) (8). Both the NCAA ISP and High School RIO utilize Web-based platforms through which sports medicine providers input data related to athletic injuries, sometimes up to a week following athlete contact (8–10). While such databases offer distinctive ability to accurately characterize the epidemiology of athletic injuries across large groups, they are not designed for real-time use. In contrast, the mobile nature of tools like the AID platform through REDCap fosters opportunities for analyzing and improving the immediate and longitudinal clinic care of injured athletes, in addition to epidemiologic surveillance.
The injuries documented in the AID reflect expected patterns, based on other national high school injury databases and published reports (1,9,10). The largest proportion of injury encounters occurred in competition (53%) and involved athletes participating in football, soccer, or basketball. While the greatest number of injury contacts documented in the AID were among males and football athletes, this is likely due at least in part to the fact that the greatest number of ATs are assigned to cover football teams and physicians primarily cover football games, representing disproportionate sideline contact, and may not be strictly due to increased injury risk in football. Most injury contacts were related to lower extremity injuries, with 22% knee, 22% ankle, and 16% other non-knee, non-ankle-related lower extremity presentations. These patterns are consistent with a recent epidemiologic study documenting injury trends captured through the National High School Sports-Related Injury Surveillance Study from 2005 through 2014, in which the majority of injuries (60.4%) occurred in competition, the highest injury rate was in football (26.5 per 100,000 athlete-exposures), and the most commonly injured body area was the knee (33.7%) (10). Similarities between the injury patterns reported in national high school injury database systems and the AID support the validity of the AID as an accurate reflection of expected injury patterns and its utility for comprehensive documentation. Our initial findings provide a baseline for ongoing monitoring, and in the future, if injury-related trends are noted within a specific school or sport, our sports medicine outreach program could target injury prevention programs toward areas of highest need during an athletic season.
The strengths of our study include the large number of sideline athlete encounters captured through the AID in 2 yr of implementation even within a small geographic area. This suggests that sports medicine providers can easily capture sideline encounter details to document athlete contact, sideline clinical demand, and local injury trends that can direct targeted interventions and injury prevention programs. There is high potential for use of the AID related to quality improvement and practice-based learning and improvement initiatives within sports medicine programs. Limitations of our study include low physician response rate to the AID user-satisfaction survey. This reflects our findings that the AID was predominantly used by ATs. Thus, ATs may have more investment in the functionality of the AID than the sports medicine physicians. Our descriptive analysis of the implementation of the AID also highlighted some limitations of the current design of the AID, particularly related to its failure to systematically capture some details of injuries, thereby limiting the specificity of injury identification. We recommend modifying the AID infrastructure to improve the specificity of data capture, specifically related to detailed injury diagnosis. This also would optimize the AID’s utility for more detailed future research of the epidemiology of sports-related injuries among athletes. Additionally, encounters for concussions are captured using a separate database and are not captured in the AID due to institutional preferences related to concussion research. In the future, inclusion of concussions and revision of data capture within the AID would expand its utility and comprehensiveness for planned research activities.
In general, mobile device-based documentation systems should ideally allow for longitudinal data capture of all injury types and should be designed such that users can easily access an individual athlete’s past encounter records to provide continuity of care. A potential future innovation is the development of mobile-based technologies, such as the AID, which can communicate directly with institutional electronic medical records, thereby improving the continuity of care for injured athletes who are subsequently seen in clinic or inpatient settings.
We describe the implementation of a new mobile device-based tool, the Sports Medicine Outreach AID, for documentation of sideline evaluations of injured athletes by ATs and Sports Medicine physicians between July 2013 and June 2015. Specifically, we describe the implementation of the AID as defined by three outcomes: Sports Medicine providers’ patterns of AID use, the nature of sideline athlete encounters captured through AID use, and sports medicine providers’ satisfaction with AID use. A mobile device-based electronic documentation system could improve the broader sports medicine community's ability to efficiently document sideline encounters with athletes as compared with traditional written documentation. Access to shared electronic databases improves communication within health care systems by facilitating continuity of care between initial sideline providers and physicians who see athletes in outpatient follow-up settings. The ability to quickly and efficiently document all sideline encounters is essential to addressing the demand for documentation of health care provided, improves communication in the longitudinal care of injured athletes, and can assist in demonstrating the highly valuable nature of on-site ATs who are integrated into local athletic settings for the purpose of prevention and treatment of youth athletic injuries to larger institutions and organizations (5).
Our experience suggests that minimal training is required to effectively incorporate a mobile device-based tool into a treatment routine, and most providers prefer a mobile device-based electronic documentation system to a traditional written documentation system. We anticipate mobile-based documentation tools, similar to the AID, can be used by Sports Medicine providers nationwide to improve sideline documentation of athlete encounters and ultimately improve the quality of health care provided to youth athletes.
The authors declare no conflicts of interest.
This work was supported by the National Center for Advancing Translational Science of the National Institutes of Health under Award Number UL1TR00045 for use of REDCap.
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