Integrating Contextual Factors into Clinical Decision Support to Reduce Contextual Error and Improve Outcomes in Ambulatory Care

项目总结/摘要 患者背景因素是指患者环境或行为，其对于 在规划有效护理时，例如，病人无力支付昂贵的药物， 当出现药物依从性差时，特别是当费用较低时， 替代品可用。不注意上下文因素导致上下文错误时，护理计划， 因为不注意病人的情况而不适当。上下文错误与 减少医疗保健结果，过度使用和滥用医疗服务。语境错误 如果提供并提示医生使用， 在护理点的上下文信息。 拟议研究的目的，提交的特别强调通知（SEN）不- HS-16-015旨在评估通过患者背景信息增强的临床决策支持（CDS）的潜力 信息，以减少上下文错误率，改善医疗保健结果，并减少不必要的 在乎研究的第一阶段包括设计和引入被动和主动CDS 通过患者通过门户网站提供的背景信息以及 电子医疗记录，在两个广泛使用的电子病历，Cerner和史诗。在第二阶段， 患者将随机接受有或没有增强的情境化CDS的护理。到 评估干预措施对就诊期间医生行为的有效性，参与患者 将音频记录他们的访问，数据将使用经过验证的上下文进行音频和EMR编码 错误跟踪系统，上下文错误的内容编码，或“4C”。4C标记每个上下文因素， 当上下文因素被处理时，将遭遇归类为上下文化，并包含 未解决的上下文错误。在指数访问之后的四到六个月， 审查将根据首次访视时对临床表现的反应来评估结局。为 例如，一名患者的HgB A1 c升高的解决方案，其护理是通过情境化CDS告知的 表明患者由于难以给药胰岛素而需要预充式注射器， 这是一个有利的回应。此外，未经宣布的标准化患者（USP），谁是演员 将提供培训，以描述定制的标准化脚本，以评估对干预措施的反应， 如果忽略了包含复杂背景因素的情况，就会导致过度使用和误用 医疗服务，以评估干预措施对减少不必要护理的影响。 本研究将招募480例患者，在80次访视中招募20名USP，具有足够的把握度 检测临床上有意义的降低背景错误率，改善医疗保健， 引入情境化CDS后的结果和成本降低。

Project Summary/Abstract A patient contextual factor refers to a patient circumstance or behavior that is essential to address when planning effective care. For instance, a patient’s inability to pay for costly medication is a contextual factor when presenting with poor medication adherence, particularly when a less costly alternative is available. Inattention to contextual factors results in contextual errors when care plans are inappropriate because of inattention to patient context. Contextual errors are associated with diminished health care outcomes and with overuse and misuse of medical services. Contextual errors and their adverse consequences may be averted if physicians are provided and prompted to use contextual information at the point of care. The aim of the proposed research, submitted in response to Special Emphasis Notice (SEN) NOT- HS-16-015, is to assess the potential of clinical decision support (CDS) enhanced with patient contextual information to reduce contextual error rates, improve health care outcomes and reduce unnecessary care. The first phase of the study consists of designing and introducing a passive and active CDS intervention informed by contextual information provided by patients through a web-portal as well from the electronic medical record, in two widely employed EMRs, Cerner and Epic. In the second phase, patients will be randomized to receive care either with or without enhanced contextualized CDS. To assess the efficacy of the intervention on physician behavior during the encounter, participating patients will audio record their visits, and the data will be audio and EMR coded using the validated contextual error tracking system, Content Coding for Contextual Error, or “4C.” 4C tags each contextual factor and classifies the encounter as contextualized when contextual factors are addressed, and containing a contextual error when not addressed. Four to six months following the index visit a structured chart review will assess outcomes as defined by response to the clinical presentation at the index visit. For instance, resolution of an elevated HgB A1c in a patient whose care was informed by contextualized CDS indicating that the patient required pre-filled syringes because of difficulty dosing their insulin, would constitute a favorable response. In addition, unannounced standardized patients (USPs), who are actors trained to portray standardized scripts customized to assess response to the intervention, will present with cases containing complicating contextual factors that if overlooked result in overuse and misuse of medical services, to assess the impact of the intervention on reducing unnecessary care. This study, which will recruit 480 patients and engage 20 USPs in 80 visits, has sufficient power to detect clinically meaningful reductions in contextual error rates, improvement in health care outcomes and cost reductions following the introduction of contextualized CDS.