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

将背景因素纳入临床决策支持，以减少背景错误并改善门诊护理的结果

• 批准号: 9912120
• 负责人: SAUL J. WEINER
• 金额: $ 36.83万
• 依托单位: UNIVERSITY OF ILLINOIS AT CHICAGO
• 依托单位国家: 美国
• 财政年份: 2017
• 资助国家: 美国
• 起止时间: 2017-07-01 至 2022-04-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9912120
• 关键词: Integrating; Contextual; Factors; into; Clinical

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.

项目概要/摘要 患者背景因素是指对于患者的情况或行为至关重要 规划有效护理时要解决的问题。例如，患者无力支付昂贵的药物费用 服药依从性差时的背景因素，特别是在成本较低的情况下 有替代方案。当制定护理计划时，不注意情境因素会导致情境错误 由于不注意患者的情况而不合适。上下文错误与以下内容相关： 医疗保健效果下降以及医疗服务的过度使用和滥用。上下文错误 如果提供并提示医生使用，则可以避免其不良后果 护理点的上下文信息。 拟议研究的目的，是为了响应特别强调通知（SEN）而提交的，而不是- HS-16-015，用于评估根据患者情况增强临床决策支持 (CDS) 的潜力 减少上下文错误率、改善医疗保健结果并减少不必要的信息 关心。研究的第一阶段包括设计和引入被动和主动 CDS 患者通过门户网站提供的背景信息以及来自 电子病历，在两种广泛使用的 EMR（Cerner 和 Epic）中。在第二阶段， 患者将被随机分配接受有或没有增强情境化 CDS 的护理。到 评估干预措施对参与患者的医生行为的有效性 将音频记录他们的访问，并且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、上下文错误内容编码或“4C”。 4C 标记每个上下文因素并 当解决情境因素时，将遭遇分类为情境化，并包含 未解决时出现上下文错误。指数后四到六个月访问结构化图表 审查将根据初次访视时对临床表现的反应来评估结果。为了 例如，一名患者的 HgB A1c 升高得到解决，该患者的护理是通过情境化 CDS 进行通知的 表明患者由于胰岛素剂量困难而需要预装注射器， 构成有利的回应。此外，未宣布的标准化患者（USP），他们是演员 经过培训，可以描绘为评估干预反应而定制的标准化脚本，将呈现 案件包含复杂的背景因素，如果忽视，会导致过度使用和误用 医疗服务，评估干预措施对减少不必要护理的影响。 这项研究将招募 480 名患者并参与 20 位 USP 进行 80 次就诊，具有足够的功效 检测上下文错误率的临床意义降低、医疗保健的改善 引入情境化 CDS 后的成果和成本降低。

项目成果

Effect of Electronic Health Record Clinical Decision Support on Contextualization of Care: A Randomized Clinical Trial.

• DOI: 10.1001/jamanetworkopen.2022.38231
• 发表时间: 2022-10-03
• 期刊: JAMA NETWORK OPEN
• 影响因子: 13.8
• 作者: Weiner, Saul J.;Schwartz, Alan;Weaver, Frances;Galanter, William;Olender, Sarah;Kochendorfer, Karl;Binns-Calvey, Amy;Saini, Ravisha;Iqbal, Sana;Diaz, Monique;Michelfelder, Aaron;Varkey, Anita
• 通讯作者: Varkey, Anita