Integrated Clinical Prediction Rules: Bringing Evidence to Diverse Primary Care Settings

描述（由申请人提供）：随着国家继续努力控制医疗成本和提高质量，医疗信息技术为我们提供了一些最有效但尚未充分利用的工具。临床预测规则是将最先进的证据与实时患者病史、体格检查和实验室数据相结合的一线决策辅助工具。虽然临床预测规则经常得到很好的验证，但在实践中尚未得到充分利用。最近，我们的团队开发了综合临床预测规则（iCPR）系统，将cpr嵌入到全国最大的商业电子健康记录（EHR）系统中。使用这一新颖的系统，我们证明了在单一医疗机构中，在链球菌性咽喉炎和肺炎疑似病例中，提供者使用率高，抗生素处方和诊断测试订单显著减少。拟议项目的目标是将这个平台推广到不同的环境中，并创建一个工具包以进一步传播。在原iCPR项目成功的基础上，本建议的具体目标是：(1)

DESCRIPTION (provided by applicant): As the nation continues its efforts to contain healthcare costs and improve quality, healthcare information technology provides some of our most potent yet underutilized tools. Clinical prediction rules are frontline decision aids that combine state-of-the-art evidence with real-time patient history, physical examination, and laboratory data. While often well-validated, clinical prediction rules have been underutilized in practice. Recently, our team developed the integrated clinical prediction rule (iCPR) system, embedding CPRs within the nation's largest commercial electronic health record (EHR) system. Using this novel system, we demonstrated high rates of provider utilization and a significant reduction in antibiotic prescribing and diagnostic test ordering among suspected cases of strep throat and pneumonia at a single healthcare facility. The objective of the proposed project is to generalize this platform across diverse settings and create a toolkit for further dissemination. Building on the success of the original iCPR project, the specific aims of this proposal are to (1) integrate our previously tested and refined iCPR tool into the same commercial EHR in three different clinical settings, adapting the innovation to provider preference, culture, and local workflow rather than imposing a rigidly standardized tool, (2) identify and measure rate and variability of iCPR uptake across different settings, (3) determine iCPR impact on antibiotic prescribing and diagnostic test-ordering patterns across diverse clinical settings with a randomized controlled trial, and (4) use a well-established theory-driven implementation framework to identify facilitators and barriers to integration in each setting, and develop a toolkt for adapting and implementing the tool in diverse settings. To achieve these aims, we propose a five- year study in which we first adapt, integrate and usability-test the original iCPR at three new diverse sites. We will then conduct a two-year randomized controlled trial with a one-year post-trial open-access observation period to determine the persistence of: 1) the tool's utilizatio and 2) its impact on antibiotic- and test-ordering in patients with suspected strep throat or pneumonia. In the final year, study findings will be compiled into a toolkit so that any healthcare facility using the Epic EHR can integrate iCPR into its ambulatory workflow. The study uses several innovative and significant approaches, including: 1) adapting the nation's most widespread commercial EHR system; 2) building the new tool with "off-the-shelf" technology included in every Epic EHR package, so the innovation can be easily ported to all Epic EHR users; 3) using highly specific, well-validated clinical prediction rules as its core content; 4) guiding the integration process with highly generalizable usability testing techniques; and 5) using a hybrid RE-AIM and normalization process theory implementation evaluation framework. Together, these innovative approaches make iCPR uniquely suited to overcome longstanding barriers and integrate and disseminate evidence-based tools into the primary care workflow at the point of care in real time.