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

摘要/项目总结 有一个全球性的重点和迫切需要关闭以患者为中心的结果研究（PCOR）的证据 练习gap。40%的患者没有接受循证实践，20%的患者接受不必要的或不必要的治疗。 可能有害的护理，可悲的是，名单还在继续。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， 实施障碍阻碍了广泛采用。在明尼苏达大学， 实施和扩展以用户为中心的CDS系统，每年扩展超过20个用例。重要的是， 我们已经开发并实施了可互操作的和联邦资助的CDS系统。我们的医疗保健 系统利用严格的方法SCALED（SCaling AcceptablecDs）来指导CDS在整个 系统但是，目前的气候，每个医疗保健系统开发“本土”CDS的完全相同的 指导方针是站不住脚的。建设能力，以大规模和共享的方式将变革和组织振兴方案迅速转化为临床应用 有必要定期使用更新的知识库（活证据综合）进行可互操作的CDS。给定 为此，我们与数字质量测量医疗保健技术平台的开发商Alfredvita合作， 和决策支持，以制定一个可互操作的临床实践指南，利用CPG-on-FHIR（快速 医疗保健互操作性资源），以预防住院COVID-19静脉血栓栓塞（VTE）。 拟议的R18项目将调整当前部署的CDS系统，以提供VTE预防指南 对于患有创伤性脑损伤（TBI）的成年患者。我们认为这是一个理想的PCOR用例， 继续努力，打击静脉血栓栓塞在创伤和我们的经验，以前实施这一指导方针。 我们的总体目标是在我们的4个机构中成功地扩展、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型随机阶梯式楔形有效性- 在4个异构医疗保健系统中扩展CDS的实施试验。试验结果将是 使用RE-AIM进行评估。尽管尽了最大的努力，但CDS的采用很可能会在每个站点中有所不同; Aim 2将 让我们明白为什么。在目标2中，我们将在以下指导下评估各试验中心的实施流程： EPIS实施框架（决定性框架）采用混合方法。最后，变革和组织振兴方案必须 随着证据的发展，CPG得到维护。迄今为止，一个公认的证据保存程序并不 存在.在目标3中，我们将为静脉血栓栓塞预防CDS系统试行“生活指南”流程模型。 最终，该项目将在一个多样化的协作CDS社区中扩展CDS， 这一重大医疗挑战的证据。我们将吸取经验教训， 与美国创伤协会合作进行扩展。重要的是，我们将发展电子健康 记录（EHR）特定的IT剧本，用于集成可互操作的CDS。最后，我们将试行一种方法， “生活指南”，并使用它来维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.