Implementation of a Clinical Decision Support System for Children With Minor Blunt Head Trauma Who Are at Nonnegligible Risk for Traumatic Brain Injuries.

Study Objective: To determine the effect of providing risk estimates of clinically important traumatic brain injuries and management recommendations on emergency department (ED) outcomes for children with isolated intermediate Pediatric Emergency Care Applied Research Network clinically important traumatic brain injury risk factors.

Methods: This was a secondary analysis of a nonrandomized clinical trial with concurrent controls, conducted at 5 pediatric and 8 general EDs between November 2011 and June 2014, enrolling patients younger than 18 years who had minor blunt head trauma. After a baseline period, intervention sites received electronic clinical decision support providing patient-level clinically important traumatic brain injury risk estimates and management recommendations.

Use of Traumatic Brain Injury Prediction Rules With Clinical Decision Support.

Objectives: We determined whether implementing the Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) prediction rules and providing risks of clinically important TBIs (ciTBIs) with computerized clinical decision support (CDS) reduces computed tomography (CT) use for children with minor head trauma.

Methods: Nonrandomized trial with concurrent controls at 5 pediatric emergency departments (PEDs) and 8 general EDs (GEDs) between November 2011 and June 2014. Patients were <18 years old with minor blunt head trauma.

Clinical Decision Support for a Multicenter Trial of Pediatric Head Trauma: Development, Implementation, and Lessons Learned.

Introduction: For children who present to emergency departments (EDs) due to blunt head trauma, ED clinicians must decide who requires computed tomography (CT) scanning to evaluate for traumatic brain injury (TBI). The Pediatric Emergency Care Applied Research Network (PECARN) derived and validated two age-based prediction rules to identify children at very low risk of clinically-important traumatic brain injuries (ciTBIs) who do not typically require CT scans. In this case report, we describe the strategy used to implement the PECARN TBI prediction rules via electronic health record (EHR) clinical decision support (CDS) as the intervention in a multicenter clinical trial.

Use of a remote clinical decision support service for a multicenter trial to implement prediction rules for children with minor blunt head trauma.

Objective: To evaluate the architecture, integration requirements, and execution characteristics of a remote clinical decision support (CDS) service used in a multicenter clinical trial. The trial tested the efficacy of implementing brain injury prediction rules for children with minor blunt head trauma.

Materials And Methods: We integrated the Epic(®) electronic health record (EHR) with the Enterprise Clinical Rules Service (ECRS), a web-based CDS service, at two emergency departments.

Lessons learned from implementing service-oriented clinical decision support at four sites: A qualitative study.

Objective: To identify challenges, lessons learned and best practices for service-oriented clinical decision support, based on the results of the Clinical Decision Support Consortium, a multi-site study which developed, implemented and evaluated clinical decision support services in a diverse range of electronic health records.

Methods: Ethnographic investigation using the rapid assessment process, a procedure for agile qualitative data collection and analysis, including clinical observation, system demonstrations and analysis and 91 interviews.

Results: We identified challenges and lessons learned in eight dimensions: (1) hardware and software computing infrastructure, (2) clinical content, (3) human-computer interface, (4) people, (5) workflow and communication, (6) internal organizational policies, procedures, environment and culture, (7) external rules, regulations, and pressures and (8) system measurement and monitoring.

A highly scalable, interoperable clinical decision support service.

Objective: To create a clinical decision support (CDS) system that is shareable across healthcare delivery systems and settings over large geographic regions.

Materials And Methods: The enterprise clinical rules service (ECRS) realizes nine design principles through a series of enterprise java beans and leverages off-the-shelf rules management systems in order to provide consistent, maintainable, and scalable decision support in a variety of settings.

Results: The ECRS is deployed at Partners HealthCare System (PHS) and is in use for a series of trials by members of the CDS consortium, including internally developed systems at PHS, the Regenstrief Institute, and vendor-based systems deployed at locations in Oregon and New Jersey.

A pilot study of distributed knowledge management and clinical decision support in the cloud.

Objective: Implement and perform pilot testing of web-based clinical decision support services using a novel framework for creating and managing clinical knowledge in a distributed fashion using the cloud. The pilot sought to (1) develop and test connectivity to an external clinical decision support (CDS) service, (2) assess the exchange of data to and knowledge from the external CDS service, and (3) capture lessons to guide expansion to more practice sites and users.

Materials And Methods: The Clinical Decision Support Consortium created a repository of shared CDS knowledge for managing hypertension, diabetes, and coronary artery disease in a community cloud hosted by Partners HealthCare.

Using a service oriented architecture approach to clinical decision support: performance results from two CDS Consortium demonstrations.

The Clinical Decision Support Consortium has completed two demonstration trials involving a web service for the execution of clinical decision support (CDS) rules in one or more electronic health record (EHR) systems. The initial trial ran in a local EHR at Partners HealthCare. A second EHR site, associated with Wishard Memorial Hospital, Indianapolis, IN, was added in the second trial.

Clinical information system services and capabilities desired for scalable, standards-based, service-oriented decision support: consensus assessment of the Health Level 7 clinical decision support Work Group.

A standards-based, service-oriented architecture for clinical decision support (CDS) has the potential to significantly enhance CDS scalability and robustness. To enable such a CDS architecture, the Health Level 7 CDS Work Group reviewed the literature, hosted multi-stakeholder discussions, and consulted domain experts to identify and prioritize the services and capabilities required from clinical information systems (CISs) to enable service-oriented CDS. In addition, relevant available standards were identified.

Patient education program for venous thromboembolism prevention in hospitalized patients.

Purpose: Up to 15% of clinician-ordered doses of injectable pharmacological prophylaxis to prevent venous thromboembolism are not administered. Patient refusal accounts for nearly 50% of these omitted doses. We conducted a prospective cohort study to determine whether a patient education program would improve medication adherence to clinician-ordered injectable prophylactic anticoagulation.

A multi-layered framework for disseminating knowledge for computer-based decision support.

Background: There are several challenges in encoding guideline knowledge in a form that is portable to different clinical sites, including the heterogeneity of clinical decision support (CDS) tools, of patient data representations, and of workflows.

Methods: We have developed a multi-layered knowledge representation framework for structuring guideline recommendations for implementation in a variety of CDS contexts. In this framework, guideline recommendations are increasingly structured through four layers, successively transforming a narrative text recommendation into input for a CDS system.

Factors influencing alert acceptance: a novel approach for predicting the success of clinical decision support.

Background: Clinical decision support systems can prevent knowledge-based prescription errors and improve patient outcomes. The clinical effectiveness of these systems, however, is substantially limited by poor user acceptance of presented warnings. To enhance alert acceptance it may be useful to quantify the impact of potential modulators of acceptance.

Creating shareable decision support services: an interdisciplinary challenge.

Creating shareable decision support services is a complex task requiring effort from multiple interdisciplinary role players with a wide variety of experience and expertise. The CDS Consortium research project has developed such a service, defining a multi-layer representation of knowledge and building upon an architectural service design created at Partners Health Care, and is demonstrating its use in both a local and an external institutional setting. The process was iterative, and we encountered unexpected requirements based on decisions made at various points.

Coded entry versus free-text and alert overrides: what you get depends on how you ask.

Purpose: A key trade-off in computerized clinical documentation exists between collecting coded data versus free-text. Coded data are more readily computer-readable and easier to reuse in different contexts. However, clinical information often exceeds the scope of commonly available terminologies, and coding may be resisted by providers.

Physician alerts to prevent symptomatic venous thromboembolism in hospitalized patients.

Background: Venous thromboembolism (VTE) prophylaxis remains underused among hospitalized patients. We designed and carried out a large, multicenter, randomized controlled trial to test the hypothesis that an alert from a hospital staff member to the attending physician will reduce the rate of symptomatic VTE among high-risk patients not receiving prophylaxis.

Methods And Results: We enrolled patients using a validated point score system to detect hospitalized patients at high risk for symptomatic VTE who were not receiving prophylaxis.

Challenges in creating an enterprise clinical rules service.

At Partners HealthCare, we are engaged in developing and implementing a strategy for our Clinical Decision Support systems and services that will enable CDS to be made available across the enterprise, allow development of consistent standards of care regardless of where a patient presents, and permit migration of current CDS functions to a supportable and scalable model. We report here on progress toward these goals, describe steps taken and proposed, and consider remaining challenges.

Enhancing clinical problem lists through data mining and natural language processing.

The availability of timely, accurate, comprehensive, and coded clinical problem lists is essential for supporting a range of healthcare activities. Evidence and experience suggest, however, that problem lists are frequently out-of-date, sometimes omit clinically important problems, and contain uncoded entries. Here, we describe a study being performed at Partners HealthCare System to explore automated techniques for enhancing existing problem lists.

Tiering drug-drug interaction alerts by severity increases compliance rates.

Objective: Few data exist measuring the effect of differentiating drug-drug interaction (DDI) alerts in computerized provider order entry systems (CPOE) by level of severity ("tiering"). We sought to determine if rates of provider compliance with DDI alerts in the inpatient setting differed when a tiered presentation was implemented.

Design: We performed a retrospective analysis of alert log data on hospitalized patients at two academic medical centers during the period from 2/1/2004 through 2/1/2005.

Electronic alerts for hospitalized high-VTE risk patients not receiving prophylaxis: a cohort study.

Background: Despite existing consensus guidelines, venous thromboembolism (VTE) prophylaxis is underused in high-risk hospitalized patients. The present study evaluated the effects of an electronic alert to the responsible physician in a cohort of hospitalized high-risk patients not receiving VTE prophylaxis.

Methods: The absence of VTE prophylaxis orders in hospitalized patients at high-risk for VTE triggered an electronic alert to the responsible physician.

Preventing DVT and PE in hospitalized patients: improving a successful electronic alert.

At Brigham and Women's Hospital (BWH) in Boston, MA, we recently concluded a four year randomized, controlled study of the effect of electronic alerts on physician behavior in the prevention of deep vein thrombosis (DVT) or pulmonary embolism (PE). We found that the use of an electronic alert reduced the risk of DVT or PE at 90 days by 41%. Upon review of the instances where the recommended prophylaxis was not accepted, we designed enhancements to the alert.

Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network.

Confusion about patients' medication regimens during the hospital admission and discharge process accounts for many preventable and serious medication errors. Many organizations have begun to redesign their clinical processes to address this patient safety concern. Partners HealthCare, an integrated delivery network in Boston, Massachusetts, has answered this interdisciplinary challenge by leveraging its multiple outpatient electronic medical records (EMR) and inpatient computerized provider order entry (CPOE) systems to facilitate the process of medication reconciliation.