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

项目摘要/摘要 患者情境因素指的是患者的情况或行为对 在规划有效护理时解决问题。例如，患者无力支付昂贵的药物费用是 出现服药依从性差时的上下文因素，特别是当成本较低时 有替代方案可用。对背景因素的忽视导致护理计划 不适当的，因为不注意病人的情况。上下文错误与 卫生保健结果降低，过度使用和滥用医疗服务。上下文错误 如果医生被提供并促使他们使用，他们的不良后果可能会被避免 关注点的上下文信息。 针对特别强调通知(SEN)提交的拟议研究的目的不是- HS-16-015，旨在评估临床决策支持(CDS)的潜力，以增强患者的上下文 提供信息以降低情景错误率、改善医疗保健结果并减少不必要的情况 关心。研究的第一阶段包括设计和引入被动式和主动式CDS 通过患者通过门户网站提供的上下文信息以及从 电子病历，在两个广泛使用的急诊室，Cerner和Epic。在第二阶段， 患者将随机接受有或没有增强的情景CDS的护理。至 评估干预对参与患者会诊期间医生行为的效果 是否将音频记录他们的访问，数据将使用验证的上下文进行音频和EMR编码 错误跟踪系统，针对上下文错误的内容编码，或“4C”。4C标记每个上下文因素和 在处理上下文因素时，将遭遇分类为已情境化，并包含 未解决的上下文错误。索引后4至6个月访问结构化图表 审查将根据对指数访问时的临床表现的反应来评估结果。为 一例患者Hgb A1c升高的解决方案，其护理由情景CDS提供信息 表明患者由于难以给胰岛素注射而需要预先填充的注射器，将 构成了有利的回应。此外，未经宣布的标准化患者(USP)，他们是演员 培训以描绘定制的标准化脚本，以评估对干预的反应，将提供 案例包含复杂的上下文因素，如果忽视这些因素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。 这项研究将招募480名患者，并在80次访问中使用20名USP，具有足够的力量 为了检测在临床上有意义的背景错误率的降低，医疗保健的改善 采用情景CDS后的成果和成本降低。

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.