优化电子健康记录中的临床决策支持。与使用肺栓塞急诊患者处置决策工具相关的临床特征。
Optimizing Clinical Decision Support in the Electronic Health Record. Clinical Characteristics Associated with the Use of a Decision Tool for Disposition of ED Patients with Pulmonary Embolism.
作者信息
Ballard Dustin W, Vemula Ridhima, Chettipally Uli K, Kene Mamata V, Mark Dustin G, Elms Andrew K, Lin James S, Reed Mary E, Huang Jie, Rauchwerger Adina S, Vinson David R
机构信息
Dustin W. Ballard, 1600 Los Gamos Drive, Suite 220, San Rafael, CA 94903, Email:
出版信息
Appl Clin Inform. 2016 Sep 21;7(3):883-98. doi: 10.4338/ACI-2016-05-RA-0073.
OBJECTIVE
Adoption of clinical decision support (CDS) tools by clinicians is often limited by workflow barriers. We sought to assess characteristics associated with clinician use of an electronic health record-embedded clinical decision support system (CDSS).
METHODS
In a prospective study on emergency department (ED) activation of a CDSS tool across 14 hospitals between 9/1/14 to 4/30/15, the CDSS was deployed at 10 active sites with an on-site champion, education sessions, iterative feedback, and up to 3 gift cards/clinician as an incentive. The tool was also deployed at 4 passive sites that received only an introductory educational session. Activation of the CDSS - which calculated the Pulmonary Embolism Severity Index (PESI) score and provided guidance - and associated clinical data were collected prospectively. We used multivariable logistic regression with random effects at provider/facility levels to assess the association between activation of the CDSS tool and characteristics at: 1) patient level (PESI score), 2) provider level (demographics and clinical load at time of activation opportunity), and 3) facility level (active vs. passive site, facility ED volume, and ED acuity at time of activation opportunity).
RESULTS
Out of 662 eligible patient encounters, the CDSS was activated in 55%: active sites: 68% (346/512); passive sites 13% (20/150). In bivariate analysis, active sites had an increase in activation rates based on the number of prior gift cards the physician had received (96% if 3 prior cards versus 60% if 0, p<0.0001). At passive sites, physicians < age 40 had higher rates of activation (p=0.03). In multivariable analysis, active site status, low ED volume at the time of diagnosis and PESI scores I or II (compared to III or higher) were associated with higher likelihood of CDSS activation.
CONCLUSIONS
Performing on-site tool promotion significantly increased odds of CDSS activation. Optimizing CDSS adoption requires active education.
目的
临床医生对临床决策支持（CDS）工具的采用往往受到工作流程障碍的限制。我们试图评估与临床医生使用电子健康记录嵌入式临床决策支持系统（CDSS）相关的特征。
方法
在一项于2014年9月1日至2015年4月30日期间对14家医院急诊科启用CDSS工具的前瞻性研究中，CDSS被部署在10个活跃站点，配有现场支持人员、开展教育课程、提供迭代反馈，并为每位临床医生提供多达3张礼品卡作为激励。该工具也被部署在4个被动站点，这些站点仅接受了一次入门教育课程。前瞻性收集CDSS的启用情况（计算肺栓塞严重程度指数（PESI）评分并提供指导）及相关临床数据。我们使用在提供者/机构层面具有随机效应的多变量逻辑回归，以评估CDSS工具的启用与以下特征之间的关联：1）患者层面（PESI评分），2）提供者层面（启用机会时的人口统计学和临床工作量），以及3）机构层面（活跃站点与被动站点、机构急诊科就诊量以及启用机会时的急诊科 acuity）。
结果
在662例符合条件的患者就诊中，CDSS的启用率为55%：活跃站点为68%（346/512）；被动站点为13%（20/150）。在双变量分析中，活跃站点的启用率根据医生之前收到的礼品卡数量而增加（如果之前收到3张卡，启用率为96%，而如果之前收到0张卡，启用率为60%，p<0.0001）。在被动站点，年龄小于40岁的医生启用率更高（p=0.03）。在多变量分析中，活跃站点状态、诊断时急诊科就诊量低以及PESI评分I或II（与III或更高相比）与CDSS启用的可能性更高相关。
结论
进行现场工具推广显著增加了CDSS启用的几率。优化CDSS的采用需要积极的教育。
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