GARDE: Scalable Clinical Decision Support for Individualized Cancer Risk Management

项目摘要/摘要 有证据支持个性化的风险分层癌症筛查，选择性地应用特定的 筛选最适合个人的干预措施。然而，在人群中进行个性化的癌症筛查 规模需要实施个性化风险评估，这在以下方面非常具有挑战性 今天不堪重负的初级保健机构。解决这一挑战的一个很有前途的方法是将 结合电子健康记录(EHR)技术识别和管理符合条件的患者 具有先进的临床决策支持(CDS)工具和自动对话代理(“聊天机器人”)。在……里面 之前由国家癌症研究所(NCI)癌症研究信息学技术资助的研究 (ITCR)计划，我们启用了基于标准的CDS平台GARDE(遗传癌症风险检测器 用于个体化癌症筛查。Garde(I)筛选和识别符合National标准的患者 综合癌症网络(NCCN)根据他们的家族史和其他因素进行基因检测的标准 电子病历中的风险因素；以及(Ii)使用自动聊天机器人提供患者外展和教育，提供 获得基因检测和对检测结果的解释。Garde已与两家市场领先的 使用快速医疗互操作性资源(FHIR)和CDS挂钩的EHR系统(EPIC®和CERNER®) 标准。Garde已成功部署在两个学术医疗中心的临床环境中 他们各自的癌症中心(犹他大学/亨斯迈癌症研究所和纽约大学) 支持由NCI癌症登月计划(U01CA232826-Kaffingst，PI)资助的桥梁试验。 本提案总目标是在保健系统中加强和传播GARDE 包括高资源医疗中心和低资源安全网医疗系统。我们的方法将是 在实施科学框架的指导下，帮助评估实施准备情况，确定障碍 和促进者，确定适应需求，并制定执行战略。具体地说，我们将(I) 使用开源技术增强Garde的聊天机器人；(Ii)在新的合作地点部署Garde (康奈尔大学、南卡罗来纳医科大学、波弗特纪念医院)； 在这些新站点快速迭代试点实施；(Iv)迭代开发和测试实施 根据试点地点的经验编写工具包；(V)进行成本分析，以促进进一步采用；以及 (6)通过实施工具包将GARDE传播到合作地点之外，并直接 技术援助。通过广泛的传播，GARDE有可能实现基于证据的 个性化癌症筛查，通过可扩展、基于人群和 可互操作的方法。

PROJECT SUMMARY/ABSTRACT Evidence supports individualizing risk-stratified cancer screening, with selective application of specific screening interventions best suited to the individual. Yet, individualizing cancer screening at a population scale requires the implementation of personalized risk assessments which are quite challenging to achieve in today’s overwhelmed primary care settings. A promising approach to address this challenge is to automate the identification and management of eligible patients using electronic health record (EHR) technologies coupled with advanced clinical decision support (CDS) tools and automated conversational agents (“chatbots”). In previous research funded by the National Cancer Institute (NCI) Informatics Technology for Cancer Research (ITCR) program, we have enabled GARDE (Genetic Cancer Risk Detector), a standards-based CDS platform for individualized cancer screening. GARDE (i) screens and identifies patients who meet National Comprehensive Cancer Network (NCCN) criteria for genetic testing based on their family history and other risk factors in the EHR; and (ii) uses automated chatbots offering patient outreach and education, offering access to genetic testing and explanation of test results. GARDE has been integrated with two market-leading EHR systems (Epic® and Cerner®) using the Fast Healthcare Interoperability Resources (FHIR) and CDS Hooks standards. GARDE has been successfully deployed in clinical settings at two academic medical centers and their respective cancer centers (University of Utah/Huntsman Cancer Institute and New York University) in support of the BRIDGE trial, funded by the NCI Cancer Moonshot program (U01CA232826 – Kaphingst, PI). The overall objective of the present proposal is to enhance and disseminate GARDE across healthcare systems including high resource medical centers and low resource safety net healthcare systems. Our approach will be guided by implementation science frameworks that help assess implementation readiness, identify barriers and facilitators, identify needs for adaptation, and develop implementation strategies. Specifically, we will (i) enhance GARDE’s chatbots using open-source technologies; (ii) deploy GARDE at new collaborating sites (Cornell University, Medical University of South Carolina [MUSC], Beaufort Memorial Hospital); (iii) conduct rapid iterative pilot implementations at these new sites; (iv) iteratively develop and test an implementation toolkit based on experience with the pilot sites; (v) conduct a cost analysis to catalyze further adoption; and (vi) disseminate GARDE beyond the collaborating sites through the implementation toolkit and direct technical assistance. Through wide dissemination, GARDE has the potential to enable evidence-based individualized cancer screening and reduce cancer burden through a scalable, population-based, and interoperable approach.