A clinical process support system for primary care to address family stress

该建议涉及国家儿童和社会发展委员会特别关注的预防虐待和忽视儿童问题的重点， 风险人群。虐待和忽视儿童往往造成儿童身体、心理和精神上的短期和长期损害， 儿童的情感和认知发展。拟议的项目建立在有希望的数据基础上， 既往随机对照试验，基于初级保健儿科实践中筛查工具的应用 确定家庭压力源和使用严厉的惩罚，这是众所周知的，使儿童处于危险之中， 虐待和忽视儿童。儿科检查是早期识别的理想选择，因为几乎普遍存在， 重复访问。然而，这些访问，也被称为“儿童健康监督”，已被指控为一个 早期发现和预防咨询的沉重公共卫生负担， 健康风险、安全和在有限的时间内促进儿童发展。我们先前已经 建立了一个系统，通过将信息收集的负担转移到在线预览， 这个名为CHADIS的平台已经被超过一百万的父母使用。然而，当访问 范围扩大到解决敏感的家庭压力源，PCP的挑战成为临床 面试技巧，在某种程度上，最好用以证据为基础的方法来解决，即所谓的激励性方法。 面试（MI）。PCP尚未接受过MI培训，通常需要比分配给 访问这里提出的创新是在访问前在线收集数据，不仅可以发现问题， 将访谈过程分开，以便计算机收集数据，指导PCP在访视期间进行 详细介绍了同情和反思性倾听的人性要素， 可以被简单地传递。此外，创新还减少了文档负担， 后续心理教育和跟踪。这个新的家庭压力模块不仅支持一个单一的问题 访问，而且还在访问中为所有年龄段的儿童的父母创造心理社会导向， 相信PCP以及由“记忆书”和短信加强的“预期指导”。电子 将与当地转诊资源（如机构或治疗师）建立链接，因此当进行转诊时， 促进了双向通信，以及在家长同意下跟踪预约完成情况。 没有类似范围的其他临床过程支持系统，也没有连接到电子 将医疗和社会领域连接起来的护理系统。该项目涉及首先完善原型与家长 和医生的反馈，然后进行随机分组干预试验。假设的结果是 虐待和忽视儿童的报告率降低，严厉的惩罚减少，儿童的发展和 干预组的行为结果。家长对强化临床流程的满意度， 还将评估附带的好处，如降低漏诊率和推迟接种疫苗。

This proposal addresses the NICHD focus of specific interest for the prevention of child abuse and neglect in at risk populations. Child abuse and neglect often confers short- and long-term impairment of the physical, emotional, and cognitive development of children. The proposed project builds on promising data from previous randomized control trials, based on application of a screening tool in primary care pediatric practice that identifies the Family Stressors and use of harsh punishment, which are known to put children at risk for child abuse and neglect. Pediatric check-ups are ideal for early identification because of nearly universal and repeated access. However, these visits, also known as “child health supervision” have been charged with a heavy public health burden of early detection and preventive counseling for a wide variety of issues related to health risks, safety, and promoting child development during narrow time constraints. We have previously built a system to assist with this challenge by off-loading the burden of information gathering to an online previsit platform called CHADIS that has been used by over one million parents already. However, when the visit scope is broadened to addressing sensitive family stressors, the challenge for PCPs becomes one of clinical interviewing skills, that, in part, is best addressed with the evidence based approach known as motivational interviewing (MI). PCPs have not been trained for MI and it typically takes longer than the time allotted for the visit. The innovation proposed here is to collect data online before visits to not only identify problems, but also divide the interview process so that the computer collects data in a way that guides the PCP during the visit with details and suggested words (“teleprompters”) for the human elements of empathy and reflective listening that can be delivered briefly. In addition, the innovation also reduces documentation burden and creates follow-up psycho-education and tracking. This new Family Stress Module supports not only a single problem visit but also acts across visits in creating the psychosocial orientation for parents of children of all ages to confide in the PCP as well “anticipatory guidance” reinforced by “MemoryBook” and text messages. Electronic linking will be created with local referral resources, such as agencies or therapists, so when a referral is made two way communication is facilitated as well as tracking of appointment completion with the parent’s consent. There are no other clinical process support systems of similar scope and none connected to an electronic system of care bridging medical and social domains. The project involves first refining a prototype with parent and doctor feedback and then conducting a cluster randomized intervention trial. Hypothesized outcomes are lower rates of child abuse and neglect reports, less harsh punishment, as well as improved developmental and behavioral outcome in the intervention group. Parent satisfaction with the enhanced clinical process and collateral benefits, such as lower rates of missed visits and delayed vaccines will also be assessed.