Division of General Internal Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States.
Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, United States.
Appl Clin Inform. 2022 Aug;13(4):820-827. doi: 10.1055/s-0042-1756366. Epub 2022 Sep 7.
Requiring accountable justifications-visible, clinician-recorded explanations for not following a clinical decision support (CDS) alert-has been used to steer clinicians away from potentially guideline-discordant decisions. Understanding themes from justifications across clinical content areas may reveal how clinicians rationalize decisions and could help inform CDS alerts.
We conducted a qualitative evaluation of the free-text justifications entered by primary care physicians from three pilot interventions designed to reduce opioid prescribing and, in older adults, high-risk polypharmacy and overtesting. Clinicians encountered alerts when triggering conditions were met within the chart. Clinicians were asked to change their course of action or enter a justification for the action that would be displayed in the chart. We extracted all justifications and grouped justifications with common themes. Two authors independently coded each justification and resolved differences via discussion. Three physicians used a modified Delphi technique to rate the clinical appropriateness of the justifications.
There were 560 justifications from 50 unique clinicians. We grouped these into three main themes used to justify an action: (1) report of a particular diagnosis or symptom (e.g., for "anxiety" or "acute pain"); (2) provision of further contextual details about the clinical case (e.g., tried and failed alternatives, short-term supply, or chronic medication); and (3) noting communication between clinician and patient (e.g., "risks and benefits discussed"). Most accountable justifications (65%) were of uncertain clinical appropriateness.
Most justifications clinicians entered across three separate clinical content areas fit within a small number of themes, and these common rationales may aid in the design of effective accountable justification interventions. Justifications varied in terms of level of clinical detail. On their own, most justifications did not clearly represent appropriate clinical decision making.
要求临床医生对不遵循临床决策支持 (CDS) 警报的行为做出可解释的说明，这有助于引导临床医生避免潜在的与指南不符的决策。了解来自不同临床内容领域的理由主题，可以揭示临床医生如何为其决策提供依据，并为 CDS 警报的设计提供参考。
我们对来自三个试点干预项目的初级保健医生输入的 CDS 警报的自由文本理由进行了定性评估，这些干预旨在减少阿片类药物的开具以及老年人的高危药物联合使用和过度检查。当满足触发条件时，临床医生会遇到警报。临床医生被要求改变他们的行动方案，或者输入一个将在图表中显示的行动理由。我们提取了所有的理由，并将具有共同主题的理由分组。两位作者独立对每个理由进行编码，并通过讨论解决分歧。三位医生使用改良 Delphi 技术对理由的临床适宜性进行了评分。
从 50 位独特的临床医生中收集到 560 个理由。我们将这些理由分为三个主要主题，用于为行动提供依据：（1）报告特定的诊断或症状（例如，用于“焦虑”或“急性疼痛”）；（2）提供有关临床病例的进一步背景详细信息（例如，尝试和失败的替代方案、短期供应或慢性药物）；（3）记录临床医生与患者之间的沟通（例如，“风险和益处讨论”）。大多数可解释的理由（65%）在临床适宜性方面存在不确定性。
在三个不同的临床内容领域中，临床医生输入的大多数理由都符合少数几个主题，这些常见的推理可以帮助设计有效的可解释性理由干预措施。理由在临床细节的水平上有所不同。就其本身而言，大多数理由并没有清楚地代表适当的临床决策。
