Evaluation of the SCALED (SCaling AcceptabLE cDs) Approach for the Implementation of Interoperable CDS for Venous Thromboembolism Prevention

摘要/项目摘要 关闭以患者为中心的结果研究(PCOR)证据是全球的重点和迫切需要 练习GAP。40%的患者没有接受循证实践，20%的患者接受了不必要的或 可能有害的护理，可悲的是，清单还在继续。我们相信可互操作的临床决策支持(CDS) 是帮助缩小这一差距的不可或缺的解决方案；然而，糟糕的设计、缺乏互操作性和 实施障碍阻碍了广泛采用。在明尼苏达大学，我们有丰富的经验 实施和扩展以用户为中心的CDS系统，每年扩展20多个用例。重要的是 我们已经开发和实施了可互操作的和联邦资助的CDS系统。我们的医疗保健 系统利用严格的扩展方法(扩展可接受的CD)来指导CDS在 系统。但是，目前每个医疗保健系统为完全相同的目的开发“本土”CDS的环境 指导方针是站不住脚的。建立能力，以规模化和共享的方式将PCOR快速转化为床边 具有更新知识库的可互操作的CDS(活体证据合成)是必要的。vt.给出 为此，我们与Apervita合作，开发了用于数字质量测量的医疗技术平台 和决策支持，以制定可互操作的临床实践指南，利用CPG-on-FHIR(Fast 医疗保健互操作性资源)，以预防住院患者新冠肺炎静脉血栓栓塞症。 拟议的R18项目将调整目前部署的CDS系统，以提供VTE预防指南 用于成人创伤性脑损伤(TBI)患者。我们认为这是一个理想的PCOR用例 继续努力抗击创伤中的静脉血栓栓塞症，以及我们以前实施这一指南的经验。 我们的总体目标是在我们的4家机构中成功扩展、评估和维护可互操作的TBI CDS 协作网络。对于目标1，我们将进行混合型2随机阶梯楔形有效性- 实施试验，以跨4个不同的医疗保健系统扩展CDS。审判结果将是 使用RE-AIM进行评估。尽管尽了最大努力，CDS的采用很有可能在每个站点上有所不同；Aim 2将 请允许我们了解原因。在目标2中，我们将在以下指导下评估各试点的实施过程 使用混合方法的EPIS实施框架(行列式框架)。最后，变革和组织振兴方案至关重要 CPG随着证据的发展而保持不变。到目前为止，一个被接受的证据维护程序还没有 是存在的。在目标3中，我们将为VTE预防CDS系统试行“生活指南”流程模式。 最终，该项目将在不同的协作CDS社区中扩展CDS，作为一个重要的 展示了这一关键的医疗保健挑战。我们将把吸取的经验教训整合到一个计划中的国家 与美国创伤学会的参与合作进行扩展。重要的是，我们将发展电子健康 特定于Record(EHR)的IT手册，用于集成可互操作的CD。最后，我们将为 “生活指南”，并用它来支持基于证据的决策逻辑。

ABSTRACT/PROJECT SUMMARY There is a global emphasis and critical need to close the patient-centered outcomes research (PCOR) evidence to practice gap. Forty percent of patients do not receive evidence-based practice, 20% receive unnecessary or potentially harmful care, and sadly, the list continues. We believe interoperable clinical decision support (CDS) is an indispensable solution to help close this gap; however, poor design, lack of interoperability, and implementation barriers hinder broad adoption. At the University of Minnesota, we have extensive experience implementing and scaling user-centered CDS systems, with over 20 use cases scaled each year. Importantly, we have developed and implemented both interoperable and federally-funded CDS systems. Our healthcare system leverages a rigorous approach, SCALED (SCaling AcceptabLE cDs), to guide CDS scaling across the system. But, the current climate of each healthcare system developing “home-grown” CDS for the exact same guidelines is not tenable. Building capabilities to rapidly translate PCOR to the bedside at scale and share interoperable CDS routinely with an updated knowledge base (living evidence synthesis) is necessary. Given this, we partnered with Apervita, developers of a healthcare technology platform for digital quality measurement and decision support, to develop an interoperable clinical practice guideline leveraging CPG-on-FHIR (Fast Healthcare Interoperability Resources) to prevent inpatient COVID-19 venous thromboembolism (VTE). The proposed R18 project will adapt a currently deployed CDS system to also deliver a VTE prevention guideline for adult patients with traumatic brain injury (TBI). We believe this is an ideal PCOR use case given PCORI’s continued effort to combat VTE in trauma and our experience previously implementing this guideline. Our overall goal is to successfully scale, evaluate, and maintain an interoperable TBI CDS across our 4-institution collaborative network. For Aim 1, we will conduct a Hybrid Type 2 randomized stepped wedge effectiveness- implementation trial to scale the CDS across 4 heterogeneous healthcare systems. Trial outcomes will be assessed using RE-AIM. Despite best efforts, it highly likely CDS adoption will vary across each site; Aim 2 will allow us to understand why. In Aim 2, we will evaluate implementation processes across trial sites guided by the EPIS implementation framework (determinant framework) using mixed-methods. Finally, it is critical that PCOR CPGs are maintained as evidence evolves. To date an accepted process for evidence maintenance does not exist. In Aim 3, we will pilot a “Living Guideline” process model for the VTE prevention CDS systems. Ultimately, this project will scale CDS across a diverse collaborative CDS community serving as an important demonstration of this critical healthcare challenge. We will integrate lessons learned for a planned national scaling in collaboration with engagement of U.S. trauma societies. Importantly, we will develop electronic health record (EHR)-specific IT playbooks for integration of interoperable CDS. Finally, we will pilot an approach for the “Living Guideline” and use that to sustain evidenced-based decision logic.