Scaling Interoperable Clinical Decision Support for Patient-Centered Chronic Pain Care

项目摘要/摘要 美国继续面临与慢性疼痛和阿片类药物过量有关的公共卫生危机。三十 百分之百的美国人患有慢性非癌症疼痛，每年的成本为6000亿美元。大多数患者患有 慢性疼痛首先求助于初级保健临床医生，他们必须根据以下情况从无数治疗方案中进行选择 相对风险和收益、病史、症状和目标。最近，随着对阿片类药物相关风险的关注， 开药方的数量减少了。然而，临床专家反驳说，担心一些患者，对他们来说 与阿片类药物相关的益处大于风险，不适当地停止使用阿片类药物。不幸的是， 初级保健临床医生缺乏可用的工具来帮助他们与患者合作选择疼痛治疗 在病史、症状和目标的背景下最佳平衡风险和收益的选项。因此， 初级保健临床医生和患者将从以患者为中心的临床决策支持(CDS)中受益 共享决策制定流程。这项为期三年的建议的目标是研究适应和 实施用于疼痛治疗共享决策的现有可互操作CDS工具，并量身定制 在One佛罗里达临床研究联盟的新临床环境中提供实施支持。我们的中央 假设定制的实施支持将增加CDS的采用和共享决策。我们 进一步的假设是，共同决策的增加将导致患者结局、疼痛和 身体机能。这项拟议的研究建立在我们团队近十年的研究到设计历史的基础上， 实施并评估用于疼痛护理的CDS。这项研究符合AHRQ的PA-20-074，并与 AHRQ对阿片类药物相关研究的兴趣(NOT-HS-18-015)，以及快速医疗互操作性的使用 资源(FHIR)(非HS-19-020)。CDS的实施将以探索、准备、 实施、可持续发展(EPIS)框架。评估将按覆盖范围、有效性、 采用、实施和维护(RE-AIM)框架。我们的具体目标是：1)适应和量身定制 疼痛管理器，AHRQ的可互操作CDS工具，用于在附属于 2)评估量身定做的实施支持对疼痛的影响 管理者对疼痛治疗共享决策的采纳；3)建立可行性并获得 针对Pain Manager和Pain的有效性的多点务实试验准备的初步数据 为共享决策和患者报告的疼痛和身体功能提供量身定制的实施支持。 这项研究将为在新的临床环境中实施可互操作的CDS的策略提供证据 跨越不同类型的电子健康记录。这项研究还将为量身定制的实施战略提供信息 将在随后的混合有效性实施试验中进一步测试。共同努力，这些努力将导致 患者、临床医生和卫生系统可以用来改进的重要新技术和证据 照顾数百万遭受疼痛和其他慢性病折磨的美国人。

PROJECT SUMMARY/ABSTRACT The U.S. continues to face public health crises related to both chronic pain and opioid overdoses. Thirty percent of Americans suffer from chronic noncancer pain at a cost of $600 billion annually. Most patients with chronic pain first turn to primary care clinicians, who must choose from myriad treatment options based on relative risks and benefits, patient history, symptoms, and goals. Recently, with attention to opioid-related risks, prescribing has declined. However, clinical experts have countered with concerns that some patients, for whom opioid-related benefits outweigh risks, are being inappropriately discontinued from opioids. Unfortunately, primary care clinicians lack usable tools to help them partner with their patients in choosing pain treatment options that best balance risks and benefits in the context of patient history, symptoms, and goals. Thus, primary care clinicians and patients would benefit from patient-centered clinical decision support (CDS) for this shared decision making process. The objective of this three-year proposal is to study the adaptation and implementation of an existing interoperable CDS tool for pain treatment shared decision making, with tailored implementation support, in new clinical settings in the OneFlorida Clinical Research Consortium. Our central hypothesis is that tailored implementation support will increase CDS adoption and shared decision making. We further hypothesize that increases in shared decision making will lead to improved patient outcomes, pain and physical function. The proposed study builds on our team’s nearly ten-year history of research to design, implement, and evaluate CDS for pain care. The study responds to AHRQ’s PA-20-074 and aligns with AHRQ’s interest in opioid-related research (NOT-HS-18-015), and use of Fast Healthcare Interoperability Resources (FHIR) (NOT-HS-19-020). The CDS implementation will be guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. The evaluation will be organized by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Our specific aims are: 1) Adapt and tailor Pain Manager, AHRQ’s interoperable CDS tool, for implementation in primary care clinics affiliated with the OneFlorida Clinical Research Consortium; 2) Evaluate the effect of tailored implementation support on Pain Manager’s adoption for pain treatment shared decision making; and 3) Establish the feasibility and obtain preliminary data in preparation for a multi-site pragmatic trial targeting the effectiveness of Pain Manager and tailored implementation support on shared decision making and patient-reported pain and physical function. The research will generate evidence on strategies for implementing interoperable CDS in new clinical settings across different types of electronic health records. The study will also inform tailored implementation strategies to be further tested in a subsequent hybrid effectiveness-implementation trial. Together, these efforts will lead to important new technology and evidence that patients, clinicians, and health systems can use to improve care for millions of Americans who suffer from pain and other chronic conditions.