Computer Automated Developmental Surveillance and Screening (CADSS)

描述(由申请人提供)：美国有12%至16%的儿童患有发育障碍。早期干预计划改善了这些儿童的结局，而且成本效益高。儿科医学界一直在推动使用包括发育监测和筛查在内的标准化方法，尽早识别患有发育迟缓或残疾的儿童。然而，医生们列举了这些建议实施的几个障碍。现代计算机决策支持策略(CDSS)为克服这些障碍提供了最大的希望。我们开发了一种新的CDSS，用于在儿科实践中实施临床指南。CHICA(通过计算机自动化改善儿童健康)结合了三个要素：(1)以雅顿语法编码的儿科指南；(2)动态、可扫描的纸质用户界面；以及(3)与现有电子病历系统兼容的HL7界面。其结果是一个系统，既能在就诊期间向医生提供与患者相关的“及时”指南，又能准确地捕获所有与之交互的结构化数据。与CHICA的初步工作证明了使用该系统实施和评估临床指南的可行性。我们建议将CHICA扩展到包括发育监测和筛查模块。本申请的具体研究目的是(1)扩展和修改现有的基于计算机的决策支持系统(CHICA)，将2006年美国儿科学会(AAP)的发育监测和筛查算法包括在内；(2)评估CHICA系统对四个儿科诊所的发育监测和筛查做法的影响；(3)评估CHICA系统对那些被确定为具有发育筛查结果的儿童的转介、进行发育和医学评估以及早期发展干预/幼儿服务的影响；以及(4)建立一组已确认为发育障碍的儿童，并可随着时间的推移进行跟踪，以观察发育筛查的最终结果/影响。这项研究将包括一项随机试验，以比较CHICA系统实施前后发育障碍的监测、筛查、诊断和管理方面的变化。为了衡量CHICA系统对发育监测和筛查做法的影响(目标2)，我们将从医疗记录和CHICA系统收集数据。对目标2感兴趣的主要结果是9个月、18个月和30个月就诊的儿童接受发育筛查的比例。对于目标3，我们将评估儿童发育障碍管理计划的各个组成部分，以确定CHICA在管理发育障碍患者方面的效果。我们还将探讨儿童管理计划的质量方面，包括家庭参与治疗决定/规划，治疗决定是否基于初步评估并使用数据驱动的决策进行持续修改，以及管理战略是否建立在儿童的优势之上。 公共卫生相关性：项目叙事研究人员和医生组织，如美国儿科学会，呼吁儿科初级保健提供者建立一种标准化的方法来识别发育延迟，包括发育监测和筛查，以促进对患有发育障碍的儿童的早期识别和干预。然而，医生们列举了在他们的执业中实施这些建议的几个障碍。计算机决策支持系统，如我们开发的通过计算机自动化改善儿童健康(CHICA)系统，为克服这些障碍并使发育监测和筛查适应繁忙的儿科实践工作流程提供了最大的希望。

DESCRIPTION (provided by applicant): Between 12 and 16% of children in the United States have a developmental disability. Early intervention programs improve outcomes in these children, and are also cost-effective. The pediatric medical community has pushed to identify children with developmental delays or disabilities as early as possible, using a standardized approach that includes both developmental surveillance and screening. Physicians, however, cite several barriers to the implementation of these recommendations. Modern computer decision support strategies (CDSS) offer the best hope of overcoming these barriers. We have developed a novel CDSS for implementing clinical guidelines in pediatric practice. CHICA (Child Health Improvement through Computer Automation) combines three elements: (1) pediatric guidelines encoded in Arden Syntax; (2) a dynamic, scannable paper user interface; and (3) an HL7-compliant interface to existing electronic medical record systems. The result is a system that both delivers "just-in-time" patient-relevant guidelines to physicians during encounters, and accurately captures structured data from all who interact with it. Preliminary work with CHICA has demonstrated the feasibility of using the system to implement and evaluate clinical guidelines. We propose to expand CHICA to include a developmental surveillance and screening module. The specific research aims of this application are to (1) expand and modify an existing computer-based decision support system (CHICA) to include the 2006 American Academy of Pediatrics (AAP) developmental surveillance and screening algorithm; (2) evaluate the effect of the CHICA system on the developmental surveillance and screening practices of four pediatric clinics; (3) evaluate the effect of the CHICA system on referrals for developmental and medical evaluations as well as early developmental intervention/early childhood services for those children identified as having concerning developmental screening results; and (4) develop a cohort of children with identified developmental disabilities that can be followed over time in order to look at the end results/effects of developmental screening. This study will include a randomized trial to compare changes in surveillance, screening, diagnosis, and management of developmental disorders before and after implementation of the CHICA system. To measure the effect of the CHICA system on developmental surveillance and screening practices (aim 2), we will collect data from medical records and the CHICA system. The primary outcome of interest for aim 2 is the proportion of children at 9, 18, and 30 month visits who undergo developmental screening. For aim 3, we will evaluate the individual components of a child's developmental disorder management program in order to determine CHICA's effect on the management of patients with developmental disorders. We will also explore qualitative aspects of a child's management plan, including family involvement in treatment decisions/planning, whether treatment decisions are based on an initial assessment and are continuously modified using data-driven decision-making, and whether the management strategies build on the strengths of the child. PUBLIC HEALTH RELEVANCE: Project Narrative Researchers and physician organizations such as the American Academy of Pediatrics have called on pediatric primary care providers to institute a standardized approach for the identification of developmental delays that includes both developmental surveillance and screening in order to facilitate early identification and intervention for children with developmental disorders. Physicians, however, cite several barriers to the implementation of these recommendations within their practices. Computer decision support systems, such as the Child Health Improvement through Computer Automation (CHICA) system we have developed, offer the best hope of addressing these barriers and enabling developmental surveillance and screening to fit within the workflow of busy pediatric practices.