Personalizing Clinical Decision Support for Heart Failure Treatment to Clinicians' Needs

项目总结 临床决策支持(CDS)工具无处不在，可以“推动”临床医生轻松做出最佳决策， 但目前对患者预后的改善微乎其微。虽然经常被忽视，但考虑到 背景因素和尽量减少不相关的信息可以改善CDS结果。为了最大限度地减少无关紧要， 目前，传统的CDS通常是针对患者而设计的，但并不是为临床医生量身定做的。为 例如，传统的CDS解决了常见的处方误解，这些误解并不适用于所有临床医生。 然而，处方模式可以用来确定是否存在开处方的误解和 然后在个性化CDS中有条件地提供信息，以满足特定临床医生的 误解；从而最大限度地减少无关紧要和警觉疲劳。个性化的CDS可以在很大程度上 改善指南指导的管理和治疗(GDMT)，用于许多次优治疗的患者 心力衰竭和射血分数降低(HFrEF)。 目标1：设计和构建传统的和个性化的CDS原型，以解决常见的 GDMT对HFrEF的误解。我们将为4创建一个个性化和传统的CDS原型 GDMT的类别：β受体阻滞剂、萨舒比利/伐沙坦、盐皮质激素受体拮抗剂和 钠/葡萄糖共转运蛋白2抑制剂。临床医生将优先处理这些误解。传统的 CDS将解决所有优先顺序的误解，而个性化CDS将有条件地解决 基于临床医生特定处方模式的误解。为了考虑上下文因素，我们将使用 指导设计和可用性测试的实用稳健实施和可持续模型(PRISM)。 目标2：在现实世界的护理环境中试验传统和个性化的CDS工具。 目的：在一项实用的随机对照试验中，比较传统的和个性化的CDS。 同一卫生系统的心脏科和初级保健诊所将进行群组随机分配。我们将使用顺序 使用混合方法和PRISM评估指标对两种CDS工具进行比较。量化结果包括 处方的可及性、采纳性和有效性。我们将采访15名一线临床医生和5名领导人，以1) 确定影响执行结果的PRISM因素，以及2)外部传播计划。 这项建议旨在解决我的培训差距：1)EHR架构，2)行为经济学/轻推， 3)实用的试验设计。这项建议的完成将确保我发展成为一名独立的 调查人员，利用实施科学来创建创新的CDS解决方案，该解决方案 有效优化卫生系统中HFrEF的GDMT。这项研究具有重要意义，因为它具有 显著改善GDMT和HFrEF高危患者预后的潜力。我们的创新， 个性化CDS通过对两个患者进行个性化CDS，挑战了一刀切CDS的现状 和临床医生；范式的转变将对CDS的发展和GDMT产生深远的影响。

PROJECT SUMMARY Clinical decision support (CDS) tools are pervasive and can “nudge” clinicians to make the best decisions easy, yet currently lead to minimal improvements in patient outcomes. Although often ignored, consideration of contextual factors and minimizing irrelevant information improves CDS outcomes. To minimize irrelevance, currently existing, ‘traditional CDS’ are often designed to be patient-specific, but are not tailored to clinicians. For example, traditional CDS address common prescribing misconceptions that are not relevant for all clinicians. However, prescribing patterns could be used to determine whether prescribing misconceptions might exist and then conditionally present information within a ‘personalized CDS’ to address a specific clinician’s misconceptions; thereby minimizing irrelevance and alert fatigue. A ‘personalized CDS’ could substantially improve guideline-directed management and therapy (GDMT) for the many suboptimally treated patients with heart failure and reduced ejection fraction (HFrEF). Aim 1: Design and build prototypes of traditional and personalized CDS to address common misconceptions of GDMT for HFrEF. We will create a personalized and traditional CDS prototype for 4 categories of GDMT: beta blockers, sacubitril/valsartan, mineralocorticoid receptor antagonists and sodium/glucose cotransport 2 inhibitors. Clinicians will prioritize the misconceptions to address. The traditional CDS will address all prioritized misconceptions, while the personalized CDS will conditionally address the misconceptions based on clinician-specific prescribing patterns. To account for contextual factors, we will use the Practical Robust Implementation and Sustainability Model (PRISM) to guide design and usability testing. Aim 2: Pilot the traditional and personalized CDS tools in real-world care settings. Aim 3: Compare the traditional and personalized CDS in a pragmatic randomized controlled trial. Cardiology and primary care clinics at one health system will be cluster-randomized. We will use sequential mixed methods and PRISM evaluation metrics to compare the two CDS tools. Quantitative outcomes include reach, adoption and effectiveness of prescribing. We will interview 15 frontline clinicians and 5 leaders to 1) identify PRISM factors influencing implementation outcomes, and 2) plan for external dissemination. This proposal was designed to address my training gaps: 1) EHR architecture, 2) behavioral economics/nudges, and 3) pragmatic trial design. Completion of this proposal will ensure my development into an independent investigator that leverages implementation science to create innovative CDS solutions that consistently and effectively optimize GDMT for HFrEF across health systems. This research is significant because it has the potential to substantially improve GDMT and outcomes for high-risk patients with HFrEF. Our innovative, personalized CDS challenges the status quo of “one size fits all” CDS by individualizing CDS to both patients and clinicians; a paradigm-shift that will have far-reaching influence on CDS development and GDMT.