The Potential for Clinical Decision Support to Improve Emergency Care

Can emergency department provider notes help to achieve more dynamic clinical decision support?

OBJECTIVE

Assess whether clinical data were present in emergency department (ED) provider notes at time of order entry for cervical spine (c-spine) imaging that could be used to augment or pre-populate clinical decision support (CDS) attributes.

METHODS

This Institutional Review Board-approved retrospective study, performed in a quaternary hospital, included all encounters for adult ED patients seen April 1, 2013-September 30, 2014 for a chief complaint of trauma who received c-spine computed tomography (CT) or x-ray. We assessed proportion of ED encounters with at least 1 c-spine-specific CDS rule attribute in clinical notes available at the time of imaging order and agreement between attributes in clinical notes and data entered into CDS.

RESULTS

A portion of the clinical note was submitted before imaging order in 42% (184/438) of encounters reviewed; 59.2% (109/184) of encounters with note portions submitted before imaging order had at least 1 positive CDS attribute identified supporting imaging study appropriateness; 34.8% (64/184) identified exclusion criteria where CDS appropriateness recommendations would not be applicable. 65.8% (121/184) of encounters had either a positive CDS attribute or an exclusion criterion. Concordance of c-spine CDS attributes when present in both notes and CDS was 68.4% (κ = 0.35 95% CI: 0.15-0.56; McNemar P = 0.23).

CONCLUSIONS

Clinical notes are an underutilized source of clinical attributes needed for CDS, available in a substantial percentage of encounters at the time of imaging order. Automated pre-population of imaging order requisitions with relevant clinical information extracted from electronic health record provider notes may: (1) improve ordering efficiency by reducing redundant data entry, (2) help improve clinical relevance of CDS alerts, and (3) potentially reduce provider burnout from extraneous alerts.

Scope and Influence of Electronic Health Record-Integrated Clinical Decision Support in the Emergency Department: A Systematic Review

STUDY OBJECTIVE

As electronic health records evolve, integration of computerized clinical decision support offers the promise of sorting, collecting, and presenting this information to improve patient care. We conducted a systematic review to examine the scope and influence of electronic health record-integrated clinical decision support technologies implemented in the emergency department (ED).

METHODS

A literature search was conducted in 4 databases from their inception through January 18, 2018: PubMed, Scopus, the Cumulative Index of Nursing and Allied Health, and Cochrane Central. Studies were included if they examined the effect of a decision support intervention that was implemented in a comprehensive electronic health record in the ED setting. Standardized data collection forms were developed and used to abstract study information and assess risk of bias.

RESULTS

A total of 2,558 potential studies were identified after removal of duplicates. Of these, 42 met inclusion criteria. Common targets for clinical decision support intervention included medication and radiology ordering practices, as well as more comprehensive systems supporting diagnosis and treatment for specific disease entities. The majority of studies (83%) reported positive effects on outcomes studied. Most studies (76%) used a pre-post experimental design, with only 3 (7%) randomized controlled trials.

CONCLUSION

Numerous studies suggest that clinical decision support interventions are effective in changing physician practice with respect to process outcomes such as guideline adherence; however, many studies are small and poorly controlled. Future studies should consider the inclusion of more specific information in regard to design choices, attempt to improve on uncontrolled before-after designs, and focus on clinically relevant outcomes wherever possible.

Real-Time Emergency Department Electronic Notifications Regarding High-Risk Patients: A Systematic Review

Background: To systematically review evidence on the feasibility and efficacy of real-time electronic notifications about patients at high risk of emergency department (ED) recidivism. Methods: Eight electronic databases were searched for empirical studies of real-time ED-based electronic tools, identifying adult patients at high risk of frequent utilization. Study selection and data extraction were performed independently by two reviewers. Qualitative data synthesis and assessment of strength of evidence were conducted through consensus discussion. Results: Of 2,256 records found through the search, 210 were duplicates, 2,004 were excluded based on abstract review, and 31 were excluded after full text review. The final sample consisted of 10 studies described in 11 articles describing the effect of real-time ED-based electronic notifications for high-risk patients. Three were randomized controlled trials (RCTs). All notifications were based on prespecified markers of risk. Seven studies integrated complex care plans into the electronic health record. Effect on ED use and length of stay (LOS) was mixed: nine studies reported decreased ED use, although results were statistically significant in only three studies; for LOS, one study reported a statistically significant reduction. Impact on cost and financial metrics was promising, with three (of three studies reporting this metric) showing improved organizational financial metrics. Three RCTs reported a reduction in opioid prescriptions. Conclusions: Real-time electronic notifications of ED providers regarding patients at high risk of ED recidivism are feasible. They may help reduce resource utilization and costs. Large knowledge gaps remain regarding patient- and provider-centered outcomes.

Improving geriatric prescribing in the ED: a qualitative study of facilitators and barriers to clinical decision support tool use

Quality problem or issue

Clinical decision support (CDS) may improve prescribing for older adults in the Emergency Department (ED) if adopted by providers.

Initial assessment

Existing prescribing order entry processes were mapped at an initial Veterans Administration Medical Center site, demonstrating cognitive burden, effort and safety concerns.

Choice of solution

Geriatric order sets incorporating 2012 Beers guidelines and including geriatric prescribing advice and prepopulated order options were developed.

Implementation

Geriatric order sets were implemented at two sites as part of the multicomponent 'Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department' quality improvement initiative.

Evaluation

Facilitators and barriers to order sets use at the two sites were evaluated. Phone interviews were conducted with two provider groups (n = 20), those 'EQUiPPED' with the interventions (n = 10, 5 at each site) and Comparison providers who were only exposed to order sets through a clickable option on the ED order menu within the patient's medical record (n = 10, 5 at each site). All providers were asked about order set 'use' and 'usefulness'. Users (n = 11) were asked about 'usability'.

Lessons learned

Order set adopters described 'usefulness' in terms of 'safety' and 'efficiency', whereas order set consultants and order set non-users described 'usefulness' in terms of 'information' or 'training'. Provider 'autonomy', 'comfort' level with existing tools, and 'learning curve' were stated as barriers to use.

Conclusions

Quantifying efficiency advantages and communicating safety benefit over preexisting practices and tools may improve adoption of CDS in ED and in other settings of care.

Community-acquired pneumonia management and outcomes in the era of health information technology

Pneumonia continues to be a leading cause of hospitalization and mortality. Implementation of health information technology (HIT) can lead to cost savings and improved care. In this review, we examine the literature on the use of HIT in the management of community-acquired pneumonia. We also discuss barriers to adoption of technology in managing pneumonia, the reliability and quality of electronic health data in pneumonia research, how technology has assisted pneumonia diagnosis and outcomes research. The goal of using HIT is to develop and deploy generalizable, real-time, computerized clinical decision support integrated into usual pneumonia care. A friendly user interface that does not disrupt efficiency and demonstrates improved clinical outcomes should result in widespread adoption.

Implementation of Electronic Clinical Decision Support for Pediatric Appendicitis

BACKGROUND AND OBJECTIVE

Computed tomography (CT) and ultrasound (US) are commonly used in patients with acute abdominal pain. We sought to standardize care and reduce CT use while maintaining patient safety through implementation of a multicomponent electronic clinical decision support tool for pediatric patients with possible appendicitis.

METHODS

We conducted a quasi-experimental study of children 3 to 18 years old who presented with possible appendicitis to the pediatric emergency department (ED) between January 2011 and December 2013. Outcomes were use of CT and US. Balancing measures included missed appendicitis, ED revisits within 30 days, appendiceal perforation, and ED length of stay.

RESULTS

Of 2803 patients with acute abdominal pain over the 3-year study period, 794 (28%) had appendicitis and 207 (26.1% of those with appendicitis) had a perforation. CT use during the 10-month preimplementation period was 38.8% and declined to 17.7% by the end of the study (54% relative decrease). For CT, segmented regression analysis revealed that there was a significant change in trend from the preimplementation period to implementation (monthly decrease -3.5%; 95% confidence interval: -5.9% to -0.9%; P = .007). US use was 45.7% preimplementation and 59.7% during implementation. However, there was no significant change in US or total imaging trends. There were also no statistically significant differences in rates of missed appendicitis, ED revisits within 30 days, appendiceal perforation, or ED length of stay between time periods.

CONCLUSIONS

Our electronic clinical decision support tool was associated with a decrease in CT use while maintaining safety and high quality care for patients with possible appendicitis.