Clinical Decision Support for Mild Traumatic Brain Injury

轻度创伤性脑损伤的临床决策支持

• 批准号: 8660304
• 负责人: Edward Robert Melnick
• 金额: $ 15.48万
• 依托单位: YALE UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2013
• 资助国家: 美国
• 起止时间: 2013-05-09 至 2015-04-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8660304
• 关键词: Clinical; Decision; Support; Mild; Traumatic

DESCRIPTION (provided by applicant): CANDIDATE: Dr. Edward R. Melnick is an Assistant Professor in the Department of Emergency and currently a student in the Master of Health Science Degree program with Clinical Informatics Track at the Yale University School of Medicine. His research focuses on improving clinical practice guideline implementation using computerized Clinical Decision Support (CDS). Traditional CDS consists of alerts or reminders presented to the clinician regarding patient-specific recommendations. Dr. Melnick has a track record for scholarly productivity with 13 peer-reviewed publications over the last five years. He is also an active member of the national clinical practice guideline development group for emergency medicine. The long-term goal of Dr. Melnick's research program is to become an independent investigator whose research program is aimed at changing the acute care clinical encounter paradigm by developing systematic patient-centered methods that promote transparent, shared, informed decision-making to safely reduce resource utilization. He plans to devote his career to overcoming the design challenges to effective CDS thus incorporating CDS that is useful, usable, promotes shared decision-making, and is seamlessly integrated into clinical workflow. Dr. Melnick's design innovations will change the way that health care is delivered and, subsequently, achieve a significant impact on patient outcomes, health care quality, safety, efficiency, costs, and effectiveness for all Americans. ENVIRONMENT & MENTOR: The Department of Emergency Medicine at the Yale University School of Medicine offers a fertile environment for physician-scientists committed to clinical research. The Department and University offer abundant research support and resources for professional development and research excellence. During the proposed award, Dr. Melnick will develop his skills by completing: (1) his ongoing master's of health science degree program with clinical informatics track, (2) formal coursework in human- computer interaction, medical decision-making, databases, and clinical information systems, and (3) goal- directed training activities in CDS, cognitive task analysis, human factors engineering, qualitative research methods, and implementation science under the mentorship of Drs. Shiffman and Post. Dr. Shiffman, Professor and Associate Director for the Yale Center for Medical Informatics, is a well-established researcher whose work focuses on defining systematic and replicable processes by which guideline knowledge can be translated into CDS. Dr. Post, Associate Professor and Research Director of Emergency Medicine at Yale, is an expert in Health Information Technology research using qualitative and mixed methods including experiences with focus groups, survey research, and usability testing. RESEARCH PROJECT: The objective of this project is to pilot an innovative CDS design process that produces patient-centered, useful, and usable CDS for the management of minor head injury in the emergency department (ED). The ED is the ideal setting to study overuse of diagnostic imaging as imaging rates of injured patients have tripled over ten years without a measurable improvement in patient outcomes, despite implementation of highly sensitive and specific clinical decision rules for detecting clinically important brain injury in minor head injury patients. Evidence-based best practices face barriers to implementation including: lack of awareness, agreement, and adherence. CDS offers a promising strategy to improve guideline implementation. Despite forty years of implementation attempts, CDS has not been universally adopted nor have its benefits been fully realized. Several adoption barriers have been identified with the primary challenge being the "usefulness" (whether it accomplishes its objective) and "usability" (ease-of-use) of the CDS due to poor integration into clinical workflow. This investigation will rely on qualitative methods to identify factors that promote or inhibit the appropriate use of computed tomography (CT) in patients presenting to the ED with minor head injury. Qualitative factors identified in this analysis will b integrated into the design of a patient- centered decision support tool prototype for use by patients and their provider at the bedside. This tool will undergo iterative refinement via rigorou usability testing in the usability lab and the ED in order to maximize its usefulness, efficiency, ease-of-use, user satisfaction, integration into clinical workflow, and ability to promote shared decision-making regarding the appropriate use of CT. The feasibility of implementing this patient- centered decision support at the bedside in a high-volume ED will be provide data for the subsequent clinical trial. The data generated from this pilot is critical to take my research program to the next level-an effectiveness study of the patient-centered decision support tool to safely reduce CT use. This proposal fulfills the Agency for Healthcare Research and Quality (AHRQ) research priority of training investigators in health information technology to improve health care decision-making and support patient-centered care. It will be piloted in the Yale-New Haven ED whose patients include an inner-city population with large minority and low- income groups-two AHRQ priority populations. The tool will include special provisions for shared decision- making with the elderly, another AHRQ priority population.

申请人描述：候选人：爱德华·R·梅尔尼克博士是急诊科助理教授，目前是耶鲁大学医学院临床信息学硕士学位课程的学生。他的研究重点是使用计算机化的临床决策支持(CDS)来改善临床实践指南的实施。传统的CDS包括向临床医生提交关于患者特定建议的警报或提醒。在过去五年里，梅尔尼克博士发表了13篇同行评议的论文，在学术成果方面有过往的记录。他也是国家急诊医学临床实践指南制定小组的积极成员。梅尔尼克博士的研究计划的长期目标是成为一名独立的调查者，其研究计划旨在通过开发以患者为中心的系统方法来改变急性护理临床遭遇范式，促进透明、共享和知情的决策，以安全地减少资源使用。他计划致力于克服有效CDS的设计挑战，从而整合有用、可用、促进共享决策并无缝集成到临床工作流程中的CDS。梅尔尼克博士的设计创新将改变医疗保健的提供方式，从而对所有美国人的患者结局、医疗质量、安全、效率、成本和有效性产生重大影响。环境与导师：耶鲁大学医学院急诊医学系为致力于临床研究的内科科学家提供了一个肥沃的环境。学院和大学为专业发展和卓越研究提供丰富的研究支持和资源。在拟议的奖项期间，梅尔尼克博士将通过完成：(1)他正在进行的具有临床信息学轨道的健康科学硕士学位计划，(2)在人机交互、医疗决策、数据库和临床信息系统方面的正式课程，以及(3)在希夫曼博士和波斯特博士的指导下，在CDS、认知任务分析、人类因素工程、定性研究方法和实施科学方面的目标导向培训活动，来发展他的技能。希夫曼博士是耶鲁大学医学信息学中心的教授兼副主任，是一位久负盛名的研究员，他的工作重点是定义系统和可复制的流程，通过这些流程可以将指南知识转化为CDS。波斯特博士是耶鲁大学急诊医学副教授兼研究主任，是使用定性和混合方法进行健康信息技术研究的专家，包括与焦点小组、调查研究和可用性测试的经验。研究项目：本项目的目标是试验一种创新的CDS设计流程，以产生以患者为中心的、有用的、可用的CDS，用于急诊科(ED)的轻微头部损伤的治疗。ED是研究过度使用诊断成像的理想场所，因为受伤患者的显像率在十年内增加了两倍，但患者预后却没有明显改善，尽管实施了高度敏感和具体的临床决策规则，以检测轻微脑损伤患者的临床重要脑损伤。基于证据的最佳实践面临 实施的障碍包括：缺乏认识、协议和遵守。CDS为改进指南的实施提供了一个很有前途的战略。尽管进行了40年的执行尝试，但CDS尚未得到普遍采用，其好处也没有完全实现。已确定了几个采用障碍，主要挑战是CDS的“有用性”(是否实现其目标)和“可用性”(易用性)，这是由于CDS与临床工作流程的集成不佳。这项调查将依靠定性方法来确定 促进或抑制向急诊室就诊的轻型颅脑损伤患者适当使用计算机断层扫描(CT)的因素。在这项分析中确定的定性因素将被整合到以患者为中心的决策支持工具原型的设计中，供患者及其床边的提供者使用。该工具将通过在可用性实验室和ED进行严格的可用性测试进行迭代改进，以最大限度地提高其有用性、效率、易用性、用户满意度、集成到临床工作流程中，以及促进关于适当使用CT的共享决策的能力。在大容量急诊室床边实施这种以患者为中心的决策支持的可行性将为后续的临床试验提供数据。这项试验产生的数据对于将我的研究计划提升到下一个水平至关重要--以患者为中心的决策支持工具的有效性研究，以安全地减少CT的使用。这项建议满足了医疗研究与质量机构(AHRQ)的研究重点，即培训卫生信息技术方面的调查人员，以改善卫生保健决策并支持以患者为中心的护理。它将在耶鲁-纽黑文教育中心进行试点，该中心的患者包括市中心的人口，其中有大量的少数族裔和低收入群体--这是AHRQ优先考虑的两个群体。该工具将包括与老年人共享决策的特别规定，老年人是AHRQ的另一个优先群体。