Averting Diagnostic Error Through Improved Recognition of Child Abuse

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Project Summary/Abstract Dr. Irit R. Rasooly’s goal is to become an independent clinician scientist dedicated to promoting accurate, timely, and equitable pediatric diagnosis. To further develop the novel skillset necessary to apply data-driven, systems-informed approaches to improve diagnosis, Dr. Rasooly’s career development plan incorporates mentored research and training in clinical informatics, longitudinal analysis, human factors engineering, implementation science, and trauma informed care. She will be mentored by experienced investigators with whom she has established, productive collaborative relationships: Dr. Christopher P. Bonafide (Primary Mentor) is an expert in developing, evaluating, and implementing interventions at the intersection of patient safety and technological innovation. Dr. Joanne N. Wood (Co-Mentor) is an expert in child physical abuse research whose scholarship has focused on racial disparities and variation in abuse evaluations. Dr. Kathy Shaw (Co-Mentor) is a national and intuitional leader in patient safety science and diagnostic error. The Children’s Hospital of Philadelphia and University of Pennsylvania are deeply supportive of Dr. Rasooly’s work and provide an unparalleled research training environment. Missed diagnosis of child abuse, in which abusive injury goes unrecognized or is misattributed to accidental trauma, is among the gravest examples of pediatric diagnostic error and a serious threat to pediatric health. While electronic health record (EHR) clinical decision support (CDS) has shown promise in improving timeliness and reducing disparities in abuse diagnosis in emergency department settings, there is a critical need for strategies to support diagnosis in primary care, where most pediatric care is delivered and where there may be opportunity to intervene before children sustain serious injuries. To lay the groundwork for creation of CDS to improve abuse diagnosis in primary care, the objective of this work is to apply EHR data- and systems-analysis to inform identification of strategies to support diagnosis of child physical abuse in primary care. Specific aims are to: (1) Detect and validate markers of physical abuse in longitudinal, clustered, EHR-derived data to distinguish young children experiencing abuse from matched controls, (2) Determine causes of abuse-related diagnostic error in primary care by conducting scenario-based high-fidelity human factors engineering EHR simulations, and (3) Identify and prioritize feasible, acceptable, and appropriate CDS strategies through a consensus approach. Findings will inform development of CDS to be tested in a future multi-center, R01 funded clinical trial. Completion of the proposed research and training will position Dr. Rasooly to launch an independent research career advancing pediatric diagnostic excellence and reducing health disparities in primary care, thereby addressing multiple AHRQ research priority areas.