KS Hendrix, SM Downs and AE Carroll,
Academic pediatrics, Mar-Apr 2015
Physicians typically respond to roughly half of the clinical decision support prompts they receive. This study was designed to test the hypothesis that selectively highlighting prompts in yellow would improve physicians' responsiveness.We conducted a randomized controlled trial using the Child Health Improvement Through Computer Automation clinical decision support system in 4 urban primary care pediatric clinics. Half of a set of electronic prompts of interest was highlighted in yellow when presented to physicians in 2 clinics. The other half of the prompts was highlighted when presented to physicians in the other 2 clinics. Analyses compared physician responsiveness to the 2 randomized sets of prompts: highlighted versus not highlighted. Additionally, several prompts deemed high priority were highlighted during the entire study period in all clinics. Physician response rates to the high-priority highlighted prompts were compared to response rates for those prompts from the year before the study period, when they were not highlighted.Physicians did not respond to prompts that were highlighted at higher rates than prompts that were not highlighted (62% and 61%, respectively; odds ratio 1.056, P = .259, NS). Similarly, physicians were no more likely to respond to high-priority prompts that were highlighted compared to the year before, when the prompts were not highlighted (59% and 59%, respectively, χ(2) = 0.067, P = .796, NS).Highlighting reminder prompts did not increase physicians' responsiveness. We provide possible explanations why highlighting did not improve responsiveness and offer alternative strategies to increasing physician responsiveness to prompts.
V Anand, S McKee, TM Dugan and SM Downs,
Applied clinical informatics, 2015
We have previously shown that a scan-able paper based interface linked to a computerized clinical decision support system (CDSS) can effectively screen patients in pediatric waiting rooms and support the physician using evidence based care guidelines at the time of clinical encounter. However, the use of scan-able paper based interface has many inherent limitations including lacking real time communication with the CDSS and being prone to human and system errors. An electronic tablet based user interface can not only overcome these limitations, but may also support advanced functionality for clinical and research use. However, use of such devices for pediatric care is not well studied in clinical settings.In this pilot study, we enhance our pediatric CDSS with an electronic tablet based user interface and evaluate it for usability as well as for changes in patient questionnaire completion rates.Child Health Improvement through Computers Leveraging Electronic Tablets or CHICLET is an electronic tablet based user interface. It is developed to augment the existing scan-able paper interface to our CDSS. For the purposes of this study, we deployed CHICLET in one outpatient pediatric clinic. Usability factors for CHICLET were evaluated via caregiver and staff surveys.When compared to the scan-able paper based interface, we observed an 18% increase or 30% relative increase in question completion rates using CHICLET. This difference was statistically significant. Caregivers and staff survey results were positive for using CHICLET in clinical environment.Electronic tablets are a viable interface for capturing patient self-report in pediatric waiting rooms. We further hypothesize that the use of electronic tablet based interfaces will drive advances in computerized clinical decision support and create opportunities for patient engagement.
NS Bauer, V Anand, AE Carroll and SM Downs,
Journal of pediatric nursing, Jan-Feb 2015
Little is known about the association of secondhand smoke (SHS) exposure and behavioral conditions among preschoolers. A cross-sectional analysis was used to examine billing and pharmacy claims from November 2004 to June 2012 linked to medical encounter-level data for 2,441 children from four pediatric community health clinics. Exposure to SHS was associated with attention deficit-hyperactivity disorder/ADHD and disruptive behavior disorder/DBD after adjusting for potential confounding factors. Assessment of exposure to SHS and parental depressive symptoms in early childhood may increase providers' ability to identify children at higher risk of behavioral issues and provide intervention at the earliest stages.
AE Carroll, NS Bauer, TM Dugan, V Anand, C Saha and SM Downs,
JAMA pediatrics, Sep 2014
Developmental delays and disabilities are common in children. Research has indicated that intervention during the early years of a child's life has a positive effect on cognitive development, social skills and behavior, and subsequent school performance.To determine whether a computerized clinical decision support system is an effective approach to improve standardized developmental surveillance and screening (DSS) within primary care practices.In this cluster randomized clinical trial performed in 4 pediatric clinics from June 1, 2010, through December 31, 2012, children younger than 66 months seen for primary care were studied.We compared surveillance and screening practices after adding a DSS module to an existing computer decision support system.The rates at which children were screened for developmental delay.Medical records were reviewed for 360 children (180 each in the intervention and control groups) to compare rates of developmental screening at the 9-, 18-, or 30-month well-child care visits. The DSS module led to a significant increase in the percentage of patients screened with a standardized screening tool (85.0% vs 24.4%, P < .001). An additional 120 records (60 each in the intervention and control groups) were reviewed to examine surveillance rates at visits outside the screening windows. The DSS module led to a significant increase in the percentage of patients whose parents were assessed for concerns about their child's development (71.7% vs 41.7%, P = .04).Using a computerized clinical decision support system to automate the screening of children for developmental delay significantly increased the numbers of children screened at 9, 18, and 30 months of age. It also significantly improved surveillance at other visits. Moreover, it increased the number of children who ultimately were diagnosed as having developmental delay and who were referred for timely services at an earlier age.clinicaltrials.gov Identifier: NCT01351077.
WE Bennett, KS Hendrix, RT Thompson-Fleming, SM Downs and AE Carroll,
European journal of pediatrics, Jul 2014
Both the American Academy of Pediatrics (AAP) and the Institute of Medicine (IOM) recommend delaying the introduction of cow's milk until after 1 year of age due to its low absorbable iron content. We used a novel computerized decision support system to gather data from multiple general pediatrics offices. We asked families whether their child received cow's milk before 1 year of age, had a low-iron diet, or used low-iron formula. Then, at subsequent visits, we performed a modified developmental assessment using the Denver II. We assessed the effect of early cow's milk or a low-iron diet on the later failure of achieving developmental milestones. We controlled for covariates using logistic regression. Early cow's milk introduction (odds ratio (OR) 1.30, p = 0.012), as well as a low-iron diet or low-iron formula (OR 1.42, p < 0.001), was associated with increased rates of milestone failure. Only personal-social milestones (OR 1.44, p = 0.002) showed a significantly higher rate of milestone failure. Both personal-social (OR 1.42, p < 0.001) and language (OR 1.22, p = 0.009) showed higher rates of failure in children with a low-iron diet.There is an association between the introduction of cow's milk before 1 year of age and the rate of delayed developmental milestones after 1 year of age. This adds strength to the recommendations from the AAP and IOM to delay cow's milk introduction until after 1 year of age.
KS Hendrix, AE Carroll and SM Downs,
Clinical pediatrics, Jun 2014
To measure the relationship between screen exposure and obesity in a large, urban sample of children and to examine whether the relationship is moderated by sociodemographics.We asked parents of 11 141 children visiting general pediatrics clinics if the child had a television (TV) in the bedroom and/or watched more than 2 hours of TV/computer daily. We measured children's height and weight, then used logistic regression to determine whether screen exposure indicators predicted obesity (body mass index ≥ 85th percentile) and interacted with race/ethnicity, sex, age, and health care payer.Having a TV in the bedroom predicted obesity risk (P = .01); however, watching TV/computer for more than 2 hours a day did not (P = 0.54). There were no interactions.Asking whether a child has a TV in the bedroom may be more important than asking about duration of screen exposure to predict risk for obesity.
V Anand, SM Downs, NS Bauer and AE Carroll,
Journal of developmental and behavioral pediatrics : JDBP, Apr 2014
Early television (TV) viewing has been linked with maternal depression and has adverse health effects in children. However, it is not known how early TV viewing occurs. This study evaluated the prevalence at which parents report TV viewing for their children if asked in the first 2 years of life and whether TV viewing is associated with maternal depression symptoms.Using a cross-sectional design, TV viewing was evaluated in children 0 to 2 years of age in 4 pediatric clinics in Indianapolis, IN, between January 2011 and April 2012. Families were screened for any parental report of depression symptoms (0-15 months) and for parental report of TV viewing (before 2 years of age) using a computerized clinical decision support system linked to the patient's electronic health record.There were 3254 children in the study. By parent report, 50% of children view TV by 2 months of age, 75% by 4 months of age, and 90% by 2 years of age. Complete data for both TV viewing and maternal depression symptoms were available for 2397 (74%) of children. In regression models, the odds of parental report of TV viewing increased by 27% for each additional month of child's age (odds ratio [OR], 1.27; 95% confidence interval [CI], 1.25-1.30; p < .001). The odds of TV viewing increased by almost half with parental report of depression symptoms (OR, 1.47; CI, 1.07-2.00, p = .016). Publicly insured children had 3 times the odds of TV viewing compared to children with private insurance (OR, 3.00; CI, 1.60-5.63; p = .001). Black children had almost 4 times the odds (OR, 3.75; CI, 2.70-5.21; p < .001), and white children had one-and-a-half times the odds (OR, 1.55; CI, 1.04-2.30; p = .032) of TV viewing when compared to Latino children.By parental report, TV viewing occurs at a very young age in infancy, usually between 0 and 3 months and varies by insurance and race/ethnicity. Children whose parents report depression symptoms are especially at risk for early TV viewing. Like maternal depression, TV viewing poses added risks for reduced interpersonal interactions to stimulate infant development. This work suggests the need to develop early targeted developmental interventions. Children as young as 0 to 3 months are viewing TV on most days. In the study sample of 0 to 2 year olds, the odds of TV viewing increased by more than a quarter for each additional month of child's age and by as much as half when the mother screened positive for depression symptoms.
NS Bauer, AE Carroll and SM Downs,
Journal of the American Medical Informatics Association : JAMIA, Jan-Feb 2014
Individual users' attitudes and opinions help predict successful adoption of health information technology (HIT) into practice; however, little is known about pediatric users' acceptance of HIT for medical decision-making at the point of care.We wished to examine the attitudes and opinions of pediatric users' toward the Child Health Improvement through Computer Automation (CHICA) system, a computer decision support system linked to an electronic health record in four community pediatric clinics. Surveys were administered in 2011 and 2012 to all users to measure CHICA's acceptability and users' satisfaction with it. Free text comments were analyzed for themes to understand areas of potential technical refinement.70 participants completed the survey in 2011 (100% response rate) and 64 of 66 (97% response rate) in 2012. Initially, satisfaction with CHICA was mixed. In general, users felt the system held promise; however various critiques reflected difficulties understanding integrated technical aspects of how CHICA worked, as well as concern with the format and wording on generated forms for families and users. In the subsequent year, users' ratings reflected improved satisfaction and acceptance. Comments also reflected a deeper understanding of the system's logic, often accompanied by suggestions on potential refinements to make CHICA more useful at the point of care.Pediatric users appreciate the system's automation and enhancements that allow relevant and meaningful clinical data to be accessible at point of care. Understanding users' acceptability and satisfaction is critical for ongoing refinement of HIT to ensure successful adoption into practice.
JG Klann, V Anand and SM Downs,
Journal of the American Medical Informatics Association : JAMIA, Dec 2013
Over 8 years, we have developed an innovative computer decision support system that improves appropriate delivery of pediatric screening and care. This system employs a guidelines evaluation engine using data from the electronic health record (EHR) and input from patients and caregivers. Because guideline recommendations typically exceed the scope of one visit, the engine uses a static prioritization scheme to select recommendations. Here we extend an earlier idea to create patient-tailored prioritization.We used Bayesian structure learning to build networks of association among previously collected data from our decision support system. Using area under the receiver-operating characteristic curve (AUC) as a measure of discriminability (a sine qua non for expected value calculations needed for prioritization), we performed a structural analysis of variables with high AUC on a test set. Our source data included 177 variables for 29 402 patients.The method produced a network model containing 78 screening questions and anticipatory guidance (107 variables total). Average AUC was 0.65, which is sufficient for prioritization depending on factors such as population prevalence. Structure analysis of seven highly predictive variables reveals both face-validity (related nodes are connected) and non-intuitive relationships.We demonstrate the ability of a Bayesian structure learning method to 'phenotype the population' seen in our primary care pediatric clinics. The resulting network can be used to produce patient-tailored posterior probabilities that can be used to prioritize content based on the patient's current circumstances.This study demonstrates the feasibility of EHR-driven population phenotyping for patient-tailored prioritization of pediatric preventive care services.
AL Gilbert, NS Bauer, AE Carroll and SM Downs,
Pediatrics, Dec 2013
To examine the association between parental report of intimate partner violence (IPV) and parental psychological distress (PPD) with child attainment of developmental milestones.By using data collected from a large cohort of primary care patients, this cross-sectional study examined the relationship between parental report of IPV and/or PPD and the attainment of developmental milestones within the first 72 months of a child's life. Multivariate logistic regression analyses were used to adjust for parental report of child abuse concern and sociodemographic characteristics.Our study population included 16 595 subjects. Children of parents reporting both IPV and PPD (n = 88; 0.5%) were more likely to fail at least 1 milestone across the following developmental domains: language (adjusted odds ratio [aOR] 2.1; 95% confidence interval [CI] 1.3-3.3), personal-social (aOR 1.9; 95% CI 1.2-2.9), and gross motor (aOR 3.0; 95% CI 1.8-5.0). Significant associations for those reporting IPV-only (n = 331; 2.0%) were found for language (aOR 1.4; 95% CI 1.1-1.9), personal-social (aOR 1.7; 95% CI 1.4-2.2), and fine motor-adaptive (aOR 1.7; 95% CI 1.0-2.7). Significant associations for those reporting PPD-only (n = 1920; 11.6%) were found for: language (aOR 1.5; 95% CI 1.3-1.7), personal-social (aOR 1.6; 95% CI 1.5-1.8), gross motor (aOR 1.6; 95% CI 1.4-1.8), and fine-motor adaptive (aOR 1.6; 95% CI 1.3-2.0).Screening children for IPV and PPD helps identify those at risk for poor developmental outcomes who may benefit from early intervention.
V Anand and SM Downs,
Pediatric allergy, immunology, and pulmonology, Sep 2013
Race and ethnicity affect children's risk of secondhand smoke exposure. However, little is known about how race and language preference impact parents' self-reported smoking and stopping smoking rates. We analyzed data for 16,523 children aged 0-11 years from a pediatric computer decision support system (Child Health Improvement through Computer Automation [CHICA]). CHICA asks families in the waiting room about household smokers. We examined associations between race, insurance, language preference, and household smoking and reported stopping smoking rates using logistic regression. Almost a quarter (23%) of the children's families reported a smoker at home. Hispanic children are least likely (odds ratio [OR]: 0.17, confidence interval [CI]: 0.12-0.24) to have secondhand smoke exposure when compared to African American and white children, as were those with private insurance (OR: 0.52, CI: 0.43-0.64) or no insurance (OR: 0.79, CI: 0.71-0.88) compared to publicly insured. Children from English speaking families were more likely (OR: 1.55, CI: 1.24-1.95) to have secondhand smoke exposure compared to Spanish speaking families. Among smoking families, 30% reported stopping smoking subsequently. Stopping rates were higher in Hispanic (OR: 3.25, CI: 2.06-5.13) and African American (OR: 1.39, CI: 1.01-1.91) families compared to white children's families. Uninsured families were less likely than publicly insured families to report stopping smoking (OR: 0.76, CI: 0.63-0.92). English speaking families were less likely (OR: 0.56, CI: 0.41-0.75) to report stopping smoking compared to Spanish speaking even in a subgroup analyses of Hispanic families (OR: 0.55, CI: 0.39-0.76). In our safety net practices serving children predominantly on public insurance, Spanish speaking families reported the lowest risk of secondhand smoke exposure in children and the highest rate of stopping smoking in the household. Hispanic families may have increasing secondhand exposure and decreasing rates of stopping smoking as they acculturate.
AE Carroll, NS Bauer, TM Dugan, V Anand, C Saha and SM Downs,
Pediatrics, Sep 2013
To determine if implementing attention-deficit/hyperactivity disorder (ADHD) diagnosis and treatment guidelines in a clinical decision support system would result in better care, including higher rates of adherence to clinical care guidelines.We conducted a cluster randomized controlled trial in which we compared diagnosis and management of ADHD in 6- to 12-year-olds after implementation of a computer decision support system in 4 practices.Eighty-four charts were reviewed. In the control group, the use of structured diagnostic assessments dropped from 50% in the baseline period to 38% in the intervention period. In the intervention group, however, it rose from 60% to 81%. This difference was statistically significant, even after controlling for age, gender, and race (odds ratio of structured diagnostic assessment in intervention group versus control group = 8.0, 95% confidence interval 1.6-40.6). Significant differences were also seen in the number of ADHD core symptoms noted at the time of diagnosis. Our study was not powered to detect changes in care and management, but the percent of patients who had documented medication adjustments, mental health referrals, and visits to mental health specialists were higher in the intervention group than the control.The introduction of a clinical decision support module resulted in higher quality of care with respect to ADHD diagnosis including a prospect for higher quality of ADHD management in children. Future work will examine how to further develop the ADHD module and add support for other chronic conditions.
NS Bauer, AL Gilbert, AE Carroll and SM Downs,
JAMA pediatrics, Apr 2013
Children with known exposure to intimate partner violence (IPV) or maternal depression are at risk for negative mental health outcomes as early as preschool age. Active ongoing surveillance for these risk factors can lead to earlier mental health intervention for children.To examine the association between parent reports of IPV and depressive symptoms within the first 3 years of a child's life with subsequent mental health conditions and psychotropic drug treatment.Prospective cohort study linking parental IPV and depression with subsequent billing and pharmacy data between November 1, 2004, and June 7, 2012.Four pediatric clinics.A total of 2422 children receiving care from clinics that implemented the Child Health Improvement Through Computer Automation (CHICA) system.Any report of IPV and/or parental depressive symptoms from birth to age 3 years, mental health diagnoses made with International Classification of Diseases, Ninth Revision criteria, and any psychotropic drug treatment between ages 3 and 6 years.Fifty-eight caregivers (2.4%) reported both IPV and depressive symptoms before their children were aged 3 years, 69 (2.8%) reported IPV only, 704 (29.1%) reported depressive symptoms only, and 1591 (65.7%) reported neither exposure. Children of parents reporting both IPV and depressive symptoms were more likely to have a diagnosis of attention-deficit/hyperactivity disorder (adjusted odds ratio = 4.0; 95% CI, 1.5-10.9), even after adjusting for the child's sex, race/ethnicity, and insurance type. Children whose parents reported depressive symptoms were more likely to have been prescribed psychotropic medication (adjusted odds ratio = 1.9; 95%, CI 1.0-3.4).Exposure to both IPV and depression before age 3 years is associated with preschool-aged onset of attention-deficit/hyperactivity disorder; early exposure to parental depression is associated with being prescribed psychotropic medication. Pediatricians play a critical role in performing active, ongoing surveillance of families with these known social risk factors and providing early intervention to negate long-term sequelae.
AE Carroll, P Biondich, V Anand, TM Dugan and SM Downs,
Journal of the American Medical Informatics Association : JAMIA, Mar-Apr 2013
To determine if automated screening and just in time delivery of testing and referral materials at the point of care promotes universal screening referral rates for maternal depression.The Child Health Improvement through Computer Automation (CHICA) system is a decision support and electronic medical record system used in our pediatric clinics. All families of patients up to 15 months of age seen between October 2007 and July 2009 were randomized to one of three groups: (1) screening questions printed on prescreener forms (PSF) completed by mothers in the waiting room with physician alerts for positive screens, (2) everything in (1) plus 'just in time' (JIT) printed materials to aid physicians, and (3) a control group where physicians were simply reminded to screen on printed physician worksheets.The main outcome of interest was whether physicians suspected a diagnosis of maternal depression and referred a mother for assistance. This occurred significantly more often in both the PSF (2.4%) and JIT groups (2.4%) than in the control group (1.2%) (OR 2.06, 95% CI 1.08 to 3.93). Compared to the control group, more mothers were noted to have depressed mood in the PSF (OR 7.93, 95% CI 4.51 to 13.96) and JIT groups (OR 8.10, 95% CI 4.61 to 14.25). Similarly, compared to the control group, more mothers had signs of anhedonia in the PSF (OR 12.58, 95% CI 5.03 to 31.46) and JIT groups (OR 13.03, 95% CI 5.21 to 32.54).Clinical decision support systems like CHICA can improve the screening of maternal depression.
AE Carroll, V Anand and SM Downs,
Applied clinical informatics, 2012
The identification of key factors influencing responses to prompts and reminders within a computer decision support system (CDSS) has not been widely studied. The aim of this study was to evaluate why clinicians routinely answer certain prompts while others are ignored.We utilized data collected from a CDSS developed by our research group--the Child Health Improvement through Computer Automation (CHICA) system. The main outcome of interest was whether a clinician responded to a prompt.This study found that, as expected, some clinics and physicians were more likely to address prompts than others. However, we also found clinicians are more likely to address prompts for younger patients and when the prompts address more serious issues. The most striking finding was that the position of a prompt was a significant predictor of the likelihood of the prompt being addressed, even after controlling for other factors. Prompts at the top of the page were significantly more likely to be answered than the ones on the bottom.This study detailed a number of factors that are associated with physicians following clinical decision support prompts. This information could be instrumental in designing better interventions and more successful clinical decision support systems in the future.
V Anand, AE Carroll and SM Downs,
Pediatrics, May 2012
Implementing US Preventive Services Task Force and American Academy of Pediatrics preventive service guidelines within the short duration of a visit is difficult because identifying which of a large number of guidelines apply to a particular patient is impractical. Clinical decision support system integrated with electronic medical records offer a good strategy for implementing screening in waiting rooms. Our objective was to determine rates of positive risk screens during typical well-care visits among children and adolescents in a primary care setting.Child Health Improvement through Computer Automation (CHICA) is a pediatric clinical decision support system developed by our research group. CHICA encodes clinical guidelines as medical logic modules to generate scanable paper forms: the patient screening form to collect structured data from patient families in the waiting room and the physician worksheet to provide physician assessments at each visit. By using visit as a unit of analysis from CHICA's database, we have determined positive risk screen rates in our population.From a cohort of 16 963 patients, 408 601 questions were asked in 31 843 visits. Of the questions asked, 362 363 (89%) had a response. Of those, 39 176 (11%) identified positive risk screens in both the younger children and the adolescent age groups.By automating the process of screening and alerting the physician to those who screened positive, we have significantly decreased the burden of identifying relevant guidelines and screening of patient families in our clinics.
V Anand, ME Sheley, S Xu and SM Downs,
Online journal of public health informatics, 2012
Rates of preventive and disease management services can be improved by providing automated alerts and reminders to primary care providers (PCPs) using of health information technology (HIT) tools.Using Adaptive Turnaround Documents (ATAD), an existing Health Information Exchange (HIE) infrastructure and office fax machines, we developed a Real Time Alert (RTA) system. RTA is a computerized decision support system (CDSS) that is able to deliver alerts to PCPs statewide for recommended services around the time of the patient visit. RTA is also able to capture structured clinical data from providers using existing fax technology. In this study, we evaluate RTA's performance for alerting PCPs when their patients with asthma have an emergency room visit anywhere in the state.Our results show that RTA was successfully able to deliver "just in time" patient-relevant alerts to PCPs across the state. Furthermore, of those ATADs faxed back and automatically interpreted by the RTA system, 35% reported finding the provided information helpful. The PCPs who reported finding information helpful also reported making a phone call, sending a letter or seeing the patient for follow up care.We have successfully demonstrated the feasibility of electronically exchanging important patient related information with the PCPs statewide. This is despite a lack of a link with their electronic health records. We have shown that using our ATAD technology, a PCP can be notified quickly of an important event such as a patient's asthma related emergency room admission so further follow up can happen in near real time.
AE Carroll, PG Biondich, V Anand, TM Dugan, ME Sheley, SZ Xu and SM Downs,
Journal of the American Medical Informatics Association : JAMIA, Jul-Aug 2011
The Child Health Improvement through Computer Automation (CHICA) system is a decision-support and electronic-medical-record system for pediatric health maintenance and disease management. The purpose of this study was to explore CHICA's ability to screen patients for disorders that have validated screening criteria--specifically tuberculosis (TB) and iron-deficiency anemia.Children between 0 and 11 years were randomized by the CHICA system. In the intervention group, parents were asked about TB and iron-deficiency risk, and physicians received a tailored prompt. In the control group, no screens were performed, and the physician received a generic prompt about these disorders.1123 participants were randomized to the control group and 1116 participants to the intervention group. Significantly more people reported positive risk factors for iron-deficiency anemia in the intervention group (17.5% vs 3.1%, OR 6.6, 95% CI 4.5 to 9.5). In general, far fewer parents reported risk factors for TB than for iron-deficiency anemia. Again, there were significantly higher detection rates of positive risk factors in the intervention group (1.8% vs 0.8%, OR 2.3, 95% CI 1.0 to 5.0).It is possible that there may be more positive screens without improving outcomes. However, the guidelines are based on studies that have evaluated the questions the authors used as sensitive and specific, and there is no reason to believe that parents misunderstood them.Many screening tests are risk-based, not universal, leaving physicians to determine who should have a further workup. This can be a time-consuming process. The authors demonstrated that the CHICA system performs well in assessing risk automatically for TB and iron-deficiency anemia.
SM Downs, V Anand, TM Dugan and AE Carroll,
AMIA ... Annual Symposium proceedings. AMIA Symposium, Nov 2010 13
Meaningful use of health information technology (HIT) requires the use of clinical decision support systems (CDSS). However, the effectiveness of CDSS depends on physician compliance with clinical reminders which is known to be highly variable. Our objective was to evaluate physician adherence to clinical reminders from a CDSS designed to maximize features known to improve practice.We evaluated physicians' compliance with clinical reminders generated by the Child Health Improvement through Computer Automation (CHICA) system, a pediatric CDSS that generates scannable paper forms that are completed by patients, staff and physicians during routine care. The forms provide tailored reminders and collect coded clinical data during routine care. We examined CHICA's database to assess the rates of response by patients and physicians to questions and reminders generated by the system. Results showed that while patients answered, on average, 60.6% of 1,351,896 questions generated by the system over 5 years, physicians responded to only 42.9% of 343,949 alerts and reminders over the same period of time. Response rates appeared to be inversely related to both the complexity and sensitivity of the topic.Poor physician adherence to clinical reminders in this optimized system reduces effectiveness of the system and poses some liability issues. Strategies to alert physicians to the reminders of highest import are needed.
SM Downs, V Zhu, V Anand, PG Biondich and AE Carroll,
AMIA ... Annual Symposium proceedings. AMIA Symposium, Nov 2008 06
Environmental tobacco smoke (ETS) exposure remains an important cause of morbidity and mortality in children. Pediatricians are well positioned to help smoking parents quit. Parents who smoke may be particularly responsive to advice to quit, repeated smoking cessation messages can be effective, and parents visit the pediatrician 8-10 times for well care in the first two years of their child's life. Yet most pediatricians do not provide smoking cessation advice. We developed a parental smoking cessation module for an established pediatric primary care decision support system (CDSS) that runs as a front-end to the Regenstrief Medical Record System. The system collects data directly from parents and guides the physician through smoking cessation counseling, using stages of change. We present the CDSS and the smoking module as well as descriptive data from our smoking cessation system. We also describe a randomized controlled trial of the system that is now underway.
SM Downs, PG Biondich, V Anand, M Zore and AE Carroll,
AMIA ... Annual Symposium proceedings. AMIA Symposium, 2006
Clinical guidelines translate complex research findings and expert opinion into actionable recommendations. However, the effectiveness of even evidence-based guidelines is rarely tested as a whole in a real clinical environment. We have developed a decision support system for implementing clinical guidelines in a busy pediatric practice. We have added to this system the ability to randomize patients to receive care with or without system support of the guideline or guideline components. The randomization is part of the Arden Syntax that implements the system logic. The result is a relatively effortless process for testing guidelines, as they are implemented, to assure that they are effective. We describe the system and the process by which this guideline evaluation functionality was built in, using two guidelines (asthma management and maternal depression screening) both of which have been applied to thousands of patients to date.
SM Downs, AE Carroll, V Anand and PG Biondich,
AMIA ... Annual Symposium proceedings. AMIA Symposium, 2005
Capturing coded clinical data for clinical decision support can improve care, but cost and disruption of clinic workflow present barriers to implementation. Previous work has shown that tailored, scannable paper forms (adaptive turnaround documents, ATDs) can achieve the benefits of computer-based clinical decision support at low cost and minimal disruption of workflow. ATDs are highly accurate under controlled circumstances, but accuracy in the setting of busy clinics with untrained physician users is untested. We recently developed and implemented such a system and studied rates of errors attributable to physician users and errors in the system. Prompts were used in 63% of encounters. Errors resulting from incorrectly marking forms occurred in 1.8% of prompts. System errors occurred in 7.2% of prompts. Most system errors were failures to capture data and may represent human errors in the scanning process. ATDs are an effective way to collect coded data from physicians. Further automation of the scanning process may reduce system errors.
PG Biondich, SM Downs, V Anand and AE Carroll,
AMIA ... Annual Symposium proceedings. AMIA Symposium, 2005
An ever-growing plethora of preventive services guidelines threatens to overwhelm primary care providers who are expected to recognize and prioritize these needed services for each patient. The Child Health Improvement through Computer Automation (CHICA) system was designed to facilitate this process through a workflow-sensitive interface that gathers and distills the most relevant patient data within pediatric settings. We evaluated family responses to 21 CHICA questions that assess risk factors and health behaviors over a three month period. 3005 patients provided 15,434 responses to these questions, and 1756 or 11.3% of these suggest risk factors which merit attention. This preliminary analysis suggests that, using CHICA, families identify significant risk factors that our clinicians acknowledge are often overlooked given the realities of practicing within this setting.
V Anand, PG Biondich, G Liu, M Rosenman and SM Downs,
Studies in health technology and informatics, 2004
Clinical guidelines are prevalent but frequently not used. Computer reminder systems can improve adherence to guidelines but have not been widely adopted. We present a computer-based decision support system that combines these elements: 1) pediatric preventive care guidelines encoded in Arden Syntax; 2) a dynamic, scannable paper user interface; and 3) a HL7-compliant interface to existing electronic medical record systems. The result is a system that both delivers "just in time" patient-relevant guidelines to physicians during the clinical encounter and accurately captures structured data from all who interact with the system. The system performs these tasks while remaining sensitive to the workflow constraints of a busy outpatient pediatric practice.
PG Biondich, V Anand, SM Downs and CJ McDonald,
AMIA ... Annual Symposium proceedings. AMIA Symposium, 2003
We developed adaptive turnaround documents (ATDs) to address longstanding challenges inherent in acquiring structured data at the point of care. These computer-generated paper forms both request and receive patient tailored information specifically for electronic storage. In our pilot, we evaluated the usability, accuracy, and user acceptance of an ATD designed to enrich a pediatric preventative care decision support system. The system had an overall digit recognition rate of 98.6% (95% CI: 98.3 to 98.9) and a marksense accuracy of 99.2% (95% CI: 99.1 to 99.3). More importantly, the system reliably extracted all data from 56.6% (95% CI: 53.3 to 59.9) of our pilot forms without the need for a verification step. These results translate to a minimal workflow burden to end users. This suggests that ATDs can serve as an inexpensive, workflow-sensitive means of structured data acquisition in the clinical setting.
SM Downs and H Uner,
Proceedings. AMIA Symposium, 2002
Computer-based prompting and reminder systems have been shown to be highly effective in increasing rates of preventive services delivery. However, there are many more recommended preventive services than can be practically included in a typical clinic visit. Therefore prioritization of preventive services prompts is necessary. We describe two approaches to prioritizing preventive services prompts based on expected value decision making. One method involves a static, global prioritization across all preventive services and has been used in a production system for almost 7 years. The second method uses influence diagrams to prioritize prompts dynamically, based on individual patient data. The latter approach is still under development. Both methods are labor intensive and require a combination of epidemiologic data and expert judgment. Compromises in strictly normative process were necessary to achieve user satisfaction.