GARDE: Scalable Clinical Decision Support for Individualized Cancer Risk Management

项目概要/摘要 证据支持个体化风险分层癌症筛查，选择性应用特定的 筛选最适合个人的干预措施。然而，对人群进行个性化癌症筛查 规模需要实施个性化的风险评估，这是相当具有挑战性的， 今天不堪重负的初级保健机构。解决这一挑战的一种有希望的方法是将 使用电子健康记录（EHR）技术识别和管理符合条件的患者 使用先进的临床决策支持（CDS）工具和自动会话代理（“聊天机器人”）。在 以前的研究由国家癌症研究所（NCI）资助的癌症研究信息技术 （ITCR）计划，我们启用了GARDE（遗传癌症风险检测器），一个基于标准的CDS平台 进行个体化癌症筛查GARDE（i）筛选和识别符合国家标准的患者 综合癌症网络（NCCN）根据其家族史和其他基因检测标准 EHR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， 获得基因检测和解释检测结果。GARDE已与两个市场领先的 使用快速医疗保健互操作性资源（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（犹他州大学/亨茨曼癌症研究所和纽约大学）， 支持由NCI癌症登月计划（U 01 CA 232826- Kaphingst，PI）资助的BRIDGE试验。 本提案的总体目标是在整个医疗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保健系统。我们的做法会有所 以有助于评估实施准备情况的实施科学框架为指导， 和促进者，确定适应需要，并制定实施战略。具体而言，我们将（i） 使用开源技术增强GARDE的聊天机器人;（ii）在新的协作站点部署GARDE （康奈尔大学、南卡罗来纳州医科大学、博福特纪念医院）;（iii）行为 在这些新站点快速迭代试验实施;（iv）迭代开发和测试实施 （五）开展成本分析，促进进一步采用; (vi)通过实施工具包，将GARDE传播到合作地点以外，并直接 技术援助。通过广泛传播，GARDE有可能使基于证据的 个体化癌症筛查，通过可扩展的、基于人群的、 互操作方法。

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.