Integrated Clinical Prediction Rules:Bringing evidence to diverse primary care se

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强大但未得到充分利用的工具。临床预测规则处于第一线 决策辅助工具，将最先进的证据与实时患者病史、体检和 实验室数据。虽然经常得到很好的验证，但临床预测规则在实践中一直没有得到充分利用。 最近，我们团队开发了综合临床预测规则(ICPR)系统，将CPR嵌入到 美国最大的商业电子健康记录(EHR)系统。使用这个新的系统，我们 显示出提供商的高使用率和抗生素处方和 在一家医疗机构订购疑似链球菌性咽喉和肺炎病例的诊断测试。 拟议项目的目标是在不同环境中推广该平台，并创建一个工具包 以便进一步传播。在原ICPR项目取得成功的基础上，本提案的具体目标 目标是(1)将我们之前经过测试和改进的ICPR工具集成到三个不同的商业EHR中 临床设置，使创新适应提供商的偏好、文化和本地工作流程，而不是 实施严格标准化的工具；(2)确定和衡量跨区域采用ICPR的速度和可变性 不同设置，(3)确定ICPR对抗生素处方和诊断性测试-订购模式的影响 通过随机对照试验跨越不同的临床环境，以及(4)使用成熟的理论驱动 实施框架，以确定每个环境中的促进者和整合障碍，并制定 用于在不同环境中调整和实施该工具的工具包。为达致这些目标，我们建议采取五项措施： 在一年的研究中，我们首先适应、集成和使用-在三个新的不同站点测试原始的ICPR。我们 然后进行为期两年的随机对照试验，试验后进行为期一年的开放观察 确定以下方面的持久性的时间段：1)工具的使用情况；2)其对抗生素和测试排序的影响 疑似链球菌性咽喉炎或肺炎的患者。在最后一年，研究结果将汇编成 因此，任何使用Epic EHR的医疗机构都可以将ICPR整合到其动态工作流程中。这个 这项研究使用了几种创新和重要的方法，包括：1)适应全国最广泛的 商业电子病历系统；2)使用每一部史诗电子病历中包含的现成技术构建新工具 包，因此创新可以轻松地移植到所有Epic EHR用户；3)使用高度具体、经过充分验证的 以临床预测规则为核心内容；4)指导集成过程，具有高度的通用性 测试技术；以及5)使用混合RE-AIM和标准化过程理论实施评估 框架。总而言之，这些创新的方法使ICPR特别适合克服长期存在的 设置障碍，并将循证工具整合和传播到初级保健工作流程中 实时的。

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 toolkit 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 utilization 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.