Effect of Electronic Health Record Clinical Decision Support on Contextualization of Care: A Randomized Clinical Trial.
Effect of Electronic Health Record Clinical Decision Support on Contextualization of Care: A Randomized Clinical Trial.
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DOI：
10.1001/jamanetworkopen.2022.38231
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发表时间：
2022-10-03
影响因子：
13.8
通讯作者：
Varkey, Anita
中科院分区：
文献类型：
--
作者：
Weiner, Saul J.;Schwartz, Alan;Weaver, Frances;Galanter, William;Olender, Sarah;Kochendorfer, Karl;Binns-Calvey, Amy;Saini, Ravisha;Iqbal, Sana;Diaz, Monique;Michelfelder, Aaron;Varkey, Anita
定制的临床决策支持（CDS）工具可以通过帮助临床医生将他们的护理情境化，为临床医生提供有关患者生活挑战的信息，从而改善患者的治疗效果吗？在这项随机临床试验中，包括452名患者的音频记录，定制的CDS工具并没有改善患者的结果，但显著改善了他们的护理情境化。本研究发现，CDS改善了护理情境化，表明该技术有可能改善患者的预后。本随机临床试验评估临床决策支持工具的使用，为初级保健临床医生提供有关护理点患者生活挑战的背景因素的信息。情境化护理是一个将个体患者的生活环境和行为信息（称为情境因素）纳入其护理计划的过程。通过4个步骤，临床医生识别线索（称为情境危险信号），临床医生询问线索（探查情境），患者披露情境因素，临床医生相应地调整护理。该流程与呈现上下文危险信号的期望结果解析相关联。确定电子健康记录（EHR）中的情境化临床决策支持（CDS）工具是否改善了临床医生的情境探索、对护理计划中情境因素的关注以及情境危险信号的呈现。本随机临床试验在2个采用不同电子病历系统的学术医疗中心的初级保健诊所进行。参与者是18岁或以上的成年人，同意在2018年9月6日至2021年3月4日期间对他们的就诊和医生进行录音。患者被随机分为干预组和对照组。在意向治疗基础上进行分析。患者完成了一份预诊问卷，该问卷引出了情境中的危险信号和因素，并出现在情境护理盒中的临床医生笔记模板中。EHR还从医疗记录中剔除危险信号，将其包含在上下文护理框中，使用被动和中断警报，并提出相关命令。6个月后在索引访问中发现的环境危险信号的比例（主要结果），探测到的危险信号的比例（次要结果），以及临床医生在护理计划中处理的环境因素的比例（次要结果），根据研究地点和访问中的多个危险信号和因素进行调整。452名患者（291名女性[65.1%]；平均[SD]年龄，55.6[15.1]岁）完成了与39名临床医生（23名女性[59.0%]）的接触。干预组与对照组相比，上下文危险信号不太可能消失（调整优势比[aOR]， 0.96 [95% CI, 0.57-1.63]）。然而，干预增加了上下文探查（aOR, 2.12 [95% CI, 1.14-3.93]）和护理计划的情境化（aOR, 2.67 [95% CI, 1.32-5.41]），控制了是否通过探查或其他方式确定因素。在整个研究组中，情境化护理计划比非情境化计划更有可能导致出现危险信号的改善（aOR, 2.13 [95% CI, 1.38-3.28]）。这项随机临床试验发现，情境化CDS并没有改善患者的预后，但确实增加了他们的护理情境化，这表明使用这种技术最终有助于改善预后。ClinicalTrials.gov标识符：NCT03244033
Can customized clinical decision support (CDS) tools that provide clinicians with information about patient life challenges improve patient outcomes by helping clinicians contextualize their care? In this randomized clinical trial that included 452 audio-recorded patient encounters, customized CDS tools did not improve patients’ outcomes but significantly improved contextualization of their care. This study found that CDS improved contextualization of care, suggesting that the technology has the potential to improve patient outcomes. This randomized clinical trial assesses the use of clinical decision support tools to provide primary care clinicians with information about contextual factors regarding patient life challenges at the point of care. Contextualizing care is a process of incorporating information about the life circumstances and behavior of individual patients, termed contextual factors, into their plan of care. In 4 steps, clinicians recognize clues (termed contextual red flags), clinicians ask about them (probe for context), patients disclose contextual factors, and clinicians adapt care accordingly. The process is associated with a desired outcome resolution of the presenting contextual red flag. To determine whether contextualized clinical decision support (CDS) tools in the electronic health record (EHR) improve clinician contextual probing, attention to contextual factors in care planning, and the presentation of contextual red flags. This randomized clinical trial was performed at the primary care clinics of 2 academic medical centers with different EHR systems. Participants were adults 18 years or older consenting to audio record their visits and their physicians between September 6, 2018, and March 4, 2021. Patients were randomized to an intervention or a control group. Analyses were performed on an intention-to-treat basis. Patients completed a previsit questionnaire that elicited contextual red flags and factors and appeared in the clinician’s note template in a contextual care box. The EHR also culled red flags from the medical record, included them in the contextual care box, used passive and interruptive alerts, and proposed relevant orders. Proportion of contextual red flags noted at the index visit that resolved 6 months later (primary outcome), proportion of red flags probed (secondary outcome), and proportion of contextual factors addressed in the care plan by clinicians (secondary outcome), adjusted for study site and for multiple red flags and factors within a visit. Four hundred fifty-two patients (291 women [65.1%]; mean [SD] age, 55.6 [15.1] years) completed encounters with 39 clinicians (23 women [59.0%]). Contextual red flags were not more likely to resolve in the intervention vs control group (adjusted odds ratio [aOR], 0.96 [95% CI, 0.57-1.63]). However, the intervention increased both contextual probing (aOR, 2.12 [95% CI, 1.14-3.93]) and contextualization of the care plan (aOR, 2.67 [95% CI, 1.32-5.41]), controlling for whether a factor was identified by probing or otherwise. Across study groups, contextualized care plans were more likely than noncontextualized plans to result in improvement in the presenting red flag (aOR, 2.13 [95% CI, 1.38-3.28]). This randomized clinical trial found that contextualized CDS did not improve patients’ outcomes but did increase contextualization of their care, suggesting that use of this technology could ultimately help improve outcomes. ClinicalTrials.gov Identifier: NCT03244033
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影响因子：
7.4
作者：
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通讯作者：
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影响因子：
5.4
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影响因子：
39.2
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通讯作者：
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影响因子：
5.7
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通讯作者：
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