Guenter Dale, Abouzahra Mohamed, Schabort Inge, Radhakrishnan Arun, Nair Kalpana, Orr Sherrie, Langevin Jessica, Taenzer Paul, Moulin Dwight E
Department of Family Medicine, McMaster University, Hamilton, ON, Canada.
College of Business, California State University, Seaside, CA, United States.
JMIR Med Inform. 2019 Sep 30;7(3):e14141. doi: 10.2196/14141.
Computerized clinical decision support systems (CDSSs) have emerged as an approach to improve compliance of clinicians with clinical practice guidelines (CPGs). Research utilizing CDSS has primarily been conducted in clinical contexts with clear diagnostic criteria such as diabetes and cardiovascular diseases. In contrast, research on CDSS for pain management and more specifically neuropathic pain has been limited. A CDSS for neuropathic pain has the potential to enhance patient care as the challenge of diagnosing and treating neuropathic pain often leads to tension in clinician-patient relationships.
The aim of this study was to design and evaluate a CDSS aimed at improving the adherence of interprofessional primary care clinicians to CPG for managing neuropathic pain.
Recommendations from the Canadian CPGs informed the decision pathways. The development of the CDSS format and function involved participation of multiple stakeholders and end users in needs assessment and usability testing. Clinicians, including family medicine physicians, residents, and nurse practitioners, in three academic teaching clinics were trained in the use of the CDSS. Evaluation over one year included the measurement of utilization of the CDSS; change in reported awareness, agreement, and adoption of CPG recommendations; and change in the observed adherence to CPG recommendations.
The usability testing of the CDSS was highly successful in the prototype environment. Deployment in the clinical setting was partially complete by the time of the study, with some limitations in the planned functionality. The study population had a high level of awareness, agreement, and adoption of guideline recommendations before implementation of CDSS. Nevertheless, there was a small and statistically significant improvement in the mean awareness and adoption scores over the year of observation (P=.01 for mean awareness scores at 6 and 12 months compared with baseline, for mean adoption scores at 6 months compared with baseline, and for mean adoption scores at 12 months). Documenting significant findings related to diagnosis of neuropathic pain increased significantly. Clinicians accessed CPG information more frequently than they utilized data entry functions. Nurse practitioners and first year family medicine trainees had higher utilization than physicians.
We observed a small increase in the adherence to CPG recommendations for managing neuropathic pain. Clinicians utilized the CDSS more as a source of knowledge and as a training tool than as an ongoing dynamic decision support.
计算机化临床决策支持系统（CDSSs）已成为提高临床医生对临床实践指南（CPGs）依从性的一种方法。利用CDSS的研究主要在具有明确诊断标准的临床环境中进行，如糖尿病和心血管疾病。相比之下，针对疼痛管理尤其是神经性疼痛的CDSS研究有限。由于诊断和治疗神经性疼痛面临挑战，这往往导致医患关系紧张，因此用于神经性疼痛的CDSS有潜力改善患者护理。
本研究旨在设计并评估一个旨在提高跨专业初级保健临床医生对管理神经性疼痛的CPG依从性的CDSS。
加拿大CPGs的建议为决策路径提供了依据。CDSS格式和功能的开发涉及多个利益相关者和最终用户参与需求评估和可用性测试。在三个学术教学诊所的临床医生，包括家庭医学医生、住院医师和执业护士，接受了CDSS使用培训。为期一年的评估包括测量CDSS的使用情况；报告的对CPG建议的知晓度、认可度和采用情况的变化；以及观察到的对CPG建议的依从性变化。
CDSS在原型环境中的可用性测试非常成功。在研究时，CDSS在临床环境中的部署部分完成，计划功能存在一些局限性。在实施CDSS之前，研究人群对指南建议的知晓度、认可度和采用率较高。然而，在观察的一年中，平均知晓度和采用率得分有小幅但具有统计学意义的提高（与基线相比，6个月和12个月时的平均知晓度得分P = 0.01，6个月时的平均采用率得分与基线相比，12个月时的平均采用率得分）。记录与神经性疼痛诊断相关的重要发现显著增加。临床医生访问CPG信息的频率高于使用数据输入功能的频率。执业护士和第一年的家庭医学实习生的使用率高于医生。
我们观察到在管理神经性疼痛方面对CPG建议的依从性有小幅提高。临床医生更多地将CDSS用作知识来源和培训工具，而不是持续的动态决策支持。
