First name
Dean
Middle name
J
Last name
Karavite

Title

Clinical Decision Support in the PICU: Implications for Design and Evaluation.

Year of Publication

2022

Date Published

2022 Apr 29

ISSN Number

1529-7535

Abstract

<p><strong>OBJECTIVES: </strong>To assess the current landscape of clinical decision support (CDS) tools in PICUs in order to identify priority areas of focus in this field.</p>

<p><strong>DESIGN: </strong>International, quantitative, cross-sectional survey.</p>

<p><strong>SETTING: </strong>Role-specific, web-based survey administered in November and December 2020.</p>

<p><strong>SUBJECTS: </strong>Medical directors, bedside nurses, attending physicians, and residents/advanced practice providers at Pediatric Acute Lung Injury and Sepsis Network-affiliated PICUs.</p>

<p><strong>INTERVENTIONS: </strong>None.</p>

<p><strong>MEASUREMENTS AND MAIN RESULTS: </strong>The survey was completed by 109 respondents from 45 institutions, primarily attending physicians from university-affiliated PICUs in the United States. The most commonly used CDS tools were people-based resources (93% used always or most of the time) and laboratory result highlighting (86%), with order sets, order-based alerts, and other electronic CDS tools also used frequently. The most important goal providers endorsed for CDS tools were a proven impact on patient safety and an evidence base for their use. Negative perceptions of CDS included concerns about diminished critical thinking and the burden of intrusive processes on providers. Routine assessment of existing CDS was rare, with infrequent reported use of observation to assess CDS impact on workflows or measures of individual alert burden.</p>

<p><strong>CONCLUSIONS: </strong>Although providers share some consensus over CDS utility, we identified specific priority areas of research focus. Consensus across practitioners exists around the importance of evidence-based CDS tools having a proven impact on patient safety. Despite broad presence of CDS tools in PICUs, practitioners continue to view them as intrusive and with concern for diminished critical thinking. Deimplementing ineffective CDS may mitigate this burden, though postimplementation evaluation of CDS is rare.</p>

DOI

10.1097/PCC.0000000000002973

Alternate Title

Pediatr Crit Care Med

PMID

35481951

Title

User Testing an Information Foraging Tool for Ambulatory Surgical Site Infection Surveillance.

Year of Publication

2018

Number of Pages

791-802

Date Published

2018 Oct

ISSN Number

1869-0327

Abstract

<p><strong>BACKGROUND: </strong> Surveillance for surgical site infections (SSIs) after ambulatory surgery in children requires a detailed manual chart review to assess criteria defined by the National Health and Safety Network (NHSN). Electronic health records (EHRs) impose an inefficient search process where infection preventionists must manually review every postsurgical encounter (&lt; 30 days). Using text mining and business intelligence software, we developed an information foraging application, the SSI Workbench, to visually present which postsurgical encounters included SSI-related terms and synonyms, antibiotic, and culture orders.</p>

<p><strong>OBJECTIVE: </strong> This article compares the Workbench and EHR on four dimensions: (1) effectiveness, (2) efficiency, (3) workload, and (4) usability.</p>

<p><strong>METHODS: </strong> Comparative usability test of Workbench and EHR. Objective test metrics are time per case, encounters reviewed per case, time per encounter, and retrieval of information meeting NHSN definitions. Subjective measures are cognitive load using the National Aeronautics and Space Administration (NASA) Task Load Index (NASA TLX), and a questionnaire on system usability and utility.</p>

<p><strong>RESULTS: </strong> Eight infection preventionists participated in the test. There was no difference in effectiveness as subjects retrieved information from all cases, using both systems, to meet the NHSN criteria. There was no difference in efficiency in time per case between the Workbench and EHR (8.58 vs. 7.39 minutes,  = 0.36). However, with the Workbench subjects opened fewer encounters per case (3.0 vs. 7.5,  = 0.002), spent more time per encounter (2.23 vs. 0.92 minutes,  = 0.002), rated the Workbench lower in cognitive load (NASA TLX, 24 vs. 33,  = 0.02), and significantly higher in measures of usability.</p>

<p><strong>CONCLUSION: </strong> Compared with the EHR, the Workbench was more usable, short, and reduced cognitive load. In overall efficiency, the Workbench did not save time, but demonstrated a shift from between-encounter foraging to within-encounter foraging and was rated as significantly more efficient. Our results suggest that infection surveillance can be better supported by systems applying information foraging theory.</p>

DOI

10.1055/s-0038-1675179

Alternate Title

Appl Clin Inform

PMID

30357777

Title

Identifying surgical site infections in electronic health data using predictive models.

Year of Publication

2018

Date Published

2018 Jun 29

ISSN Number

1527-974X

Abstract

<p><strong>Objective: </strong>The objective was to prospectively derive and validate a prediction rule for detecting cases warranting investigation for surgical site infections (SSI) after ambulatory surgery.</p>

<p><strong>Methods: </strong>We analysed electronic health record (EHR) data for children who underwent ambulatory surgery at one of 4 ambulatory surgical facilities. Using regularized logistic regression and random forests, we derived SSI prediction rules using 30 months of data (derivation set) and evaluated performance with data from the subsequent 10 months (validation set). Models were developed both with and without data extracted from free text. We also evaluated the presence of an antibiotic prescription within 60 days after surgery as an independent indicator of SSI evidence. Our goal was to exceed 80% sensitivity and 10% positive predictive value (PPV).</p>

<p><strong>Results: </strong>We identified 234 surgeries with evidence of SSI among the 7910 surgeries available for analysis. We derived and validated an optimal prediction rule that included free text data using a random forest model (sensitivity = 0.9, PPV = 0.28). Presence of an antibiotic prescription had poor sensitivity (0.65) when applied to the derivation data but performed better when applied to the validation data (sensitivity = 0.84, PPV = 0.28).</p>

<p><strong>Conclusions: </strong>EHR data can facilitate SSI surveillance with adequate sensitivity and PPV.</p>

DOI

10.1093/jamia/ocy075

Alternate Title

J Am Med Inform Assoc

PMID

29982511

Title

Genomic decision support needs in pediatric primary care.

Year of Publication

2017

Date Published

2017 Feb 19

ISSN Number

1527-974X

Abstract

<p>Clinical genome and exome sequencing can diagnose pediatric patients with complex conditions that often require follow-up care with multiple specialties. The American Academy of Pediatrics emphasizes the role of the medical home and the primary care pediatrician in coordinating care for patients who need multidisciplinary support. In addition, the electronic health record (EHR) with embedded clinical decision support is recognized as an important component in providing care in this setting. We interviewed 6 clinicians to assess their experience caring for patients with complex and rare genetic findings and hear their opinions about how the EHR currently supports this role. Using these results, we designed a candidate EHR clinical decision support application mock-up and conducted formative exploratory user testing with 26 pediatric primary care providers to capture opinions on its utility in practice with respect to a specific clinical scenario. Our results indicate agreement that the functionality represented by the mock-up would effectively assist with care and warrants further development.</p>

DOI

10.1093/jamia/ocw184

Alternate Title

J Am Med Inform Assoc

PMID

28339689

Title

Patient-generated Digital Images after Pediatric Ambulatory Surgery.

Year of Publication

2016

Number of Pages

646-52

Date Published

2016

ISSN Number

1869-0327

Abstract

<p><strong>OBJECTIVE: </strong>To describe the use of digital images captured by parents or guardians and sent to clinicians for assessment of wounds after pediatric ambulatory surgery.</p>

<p><strong>METHODS: </strong>Subjects with digital images of post-operative wounds were identified as part of an on-going cohort study of infections after ambulatory surgery within a large pediatric healthcare system. We performed a structured review of the electronic health record (EHR) to determine how digital images were documented in the EHR and used in clinical care.</p>

<p><strong>RESULTS: </strong>We identified 166 patients whose parent or guardian reported sending a digital image of the wound to the clinician after surgery. A corresponding digital image was located in the EHR in only 121 of these encounters. A change in clinical management was documented in 20% of these encounters, including referral for in-person evaluation of the wound and antibiotic prescription.</p>

<p><strong>CONCLUSION: </strong>Clinical teams have developed ad hoc workflows to use digital images to evaluate post-operative pediatric surgical patients. Because the use of digital images to support follow-up care after ambulatory surgery is likely to increase, it is important that high-quality images are captured and documented appropriately in the EHR to ensure privacy, security, and a high-level of care.</p>

DOI

10.4338/ACI-2015-12-CR-0168

Alternate Title

Appl Clin Inform

PMID

27452477

Title

A shared e-decision support portal for pediatric asthma.

Year of Publication

2014

Number of Pages

120-6

Date Published

04/2014

ISSN Number

1550-3267

Abstract

<p>We describe the user-centered development of an electronic medical record-based portal, "MyAsthma," designed to facilitate shared decision making in pediatric asthma. Interviews and focus groups with 7 parents of children with asthma and 51 clinical team members elicited 2 overarching requirements: that the portal should support sustained communication and ensure patient safety. Parents and clinicians prioritized features including collecting parent and child concerns and goals; symptom, side effect, and medication adherence tracking with decision support; and accessible educational materials. Iterative usability testing refined the system. MyAsthma provides a model for using technology to foster shared decision making in ambulatory care settings.</p>

DOI

10.1097/JAC.0000000000000025

Alternate Title

J Ambul Care Manage

PMID

24594560

Title

Improving adherence to otitis media guidelines with clinical decision support and physician feedback.

Year of Publication

2013

Number of Pages

e1071-81

Date Published

2013 Apr

ISSN Number

1098-4275

Abstract

<p><strong>OBJECTIVE: </strong>To assess the effects of electronic health record-based clinical decision support (CDS) and physician performance feedback on adherence to guidelines for acute otitis media (AOM) and otitis media with effusion (OME).</p>

<p><strong>METHODS: </strong>We conducted a factorial-design cluster randomized trial with primary care practices (n = 24) as the unit of randomization and visits as the unit of analysis. Between December 2007 and September 2010, data were collected from 139,305 otitis media visits made by 55,779 children aged 2 months to 12 years. When activated, the CDS system provided guideline-based recommendations individualized to the patient's history and presentation. Monthly physician feedback reported adherence to guideline-based care, changes over time, and comparisons to others in the practice and network.</p>

<p><strong>RESULTS: </strong>Comprehensive care (all recommended guidelines were adhered to) was accomplished for 15% of AOM and 5% of OME visits during the baseline period. The increase from baseline to intervention periods in adherence to guidelines was larger for CDS compared with non-CDS visits for comprehensive care, pain treatment, adequate diagnostic evaluation for OME, and amoxicillin as first-line therapy for AOM. Although performance feedback was associated with improved antibiotic prescribing for AOM and pain treatment, the joint effects of CDS and feedback on guideline adherence were not additive. There was marked variation in use of the CDS system, ranging from 5% to 45% visits across practices.</p>

<p><strong>CONCLUSIONS: </strong>Clinical decision support and performance feedback are both effective strategies for improving adherence to otitis media guidelines. However, combining the 2 interventions is no better than either delivered alone.</p>

DOI

10.1542/peds.2012-1988

Alternate Title

Pediatrics

PMID

23478860

Title

Adoption of electronic medical record-based decision support for otitis media in children.

Year of Publication

2015

Number of Pages

489-513

Date Published

04/2015

ISSN Number

1475-6773

Abstract

<p><strong>OBJECTIVE: </strong>Substantial investment in electronic health records (EHRs) has provided an unprecedented opportunity to use clinical decision support (CDS) to increase guideline adherence. To inform efforts to maximize adoption, we characterized the adoption of an otitis media (OM) CDS system, the impact of performance feedback on adoption, and the effects of adoption on guideline adherence.</p>

<p><strong>STUDY SETTING: </strong>A total of 41,391 OM visits with 108 clinicians at 16 pediatric practices between February 2009 and August 2010.</p>

<p><strong>STUDY DESIGN: </strong>Prospective cohort study of EHR-based CDS adoption during OM visits, comparing clinicians receiving performance feedback to none. CDS was available to all physicians; use was voluntary.</p>

<p><strong>DATA COLLECTION: </strong>Extraction from a common EHR.</p>

<p><strong>PRINCIPAL FINDINGS: </strong>Clinicians and practices used the CDS system for a mean of 21 percent (range: 0-85 percent) and 17 percent (0-51 percent) of eligible OM visits, respectively. Clinicians who received performance feedback reports summarizing CDS use and guideline adherence had a relative increase in CDS use of 9.0 percentage points compared to others (p = .001). CDS adoption was associated with increased OM guideline adherence. Effects were greatest among clinicians with the lowest adherence prior to the study.</p>

<p><strong>CONCLUSIONS: </strong>Performance feedback increased CDS adoption, but additional strategies are needed to integrate CDS into primary care workflows.</p>

DOI

10.1111/1475-6773.12240

Alternate Title

Health Serv Res

PMID

25287670

Title

Parent-reported outcomes of a shared decision-making portal in asthma: a practice-based RCT.

Year of Publication

2015

Number of Pages

e965-73

Date Published

04/2015

ISSN Number

1098-4275

Abstract

<p><strong>BACKGROUND: </strong>Electronic health record (EHR)-linked patient portals are a promising approach to facilitate shared decision-making between families of children with chronic conditions and pediatricians. This study evaluated the feasibility, acceptability, and impact of MyAsthma, an EHR-linked patient portal supporting shared decision-making for pediatric asthma.</p>

<p><strong>METHODS: </strong>We conducted a 6-month randomized controlled trial of MyAsthma at 3 primary care practices. Families were randomized to MyAsthma, which tracks families' asthma treatment concerns and goals, children's asthma symptoms, medication side effects and adherence, and provides decision support, or to standard care. Outcomes included the feasibility and acceptability of MyAsthma for families, child health care utilization and asthma control, and the number of days of missed school (child) and work (parent). Descriptive statistics and longitudinal regression models assessed differences in outcomes between study arms.</p>

<p><strong>RESULTS: </strong>We enrolled 60 families, 30 in each study arm (mean age 8.3 years); 57% of parents in the intervention group used MyAsthma during at least 5 of the 6 study months. Parents of children with moderate to severe persistent asthma used the portal more than others; 92% were satisfied with MyAsthma. Parents reported that use improved their communication with the office, ability to manage asthma, and awareness of the importance of ongoing attention to treatment. Parents in the intervention group reported that children had a lower frequency of asthma flares and intervention parents missed fewer days of work due to asthma.</p>

<p><strong>CONCLUSIONS: </strong>Use of an EHR-linked asthma portal was feasible and acceptable to families and improved clinically meaningful outcomes.</p>

DOI

10.1542/peds.2014-3167

Alternate Title

Pediatrics

PMID

25755233

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