Addressing Barriers to Broad Dissemination of EHR-embedded Child Abuse Clinical Decision Support

Background: Child maltreatment is a leading cause of morbidity and mortality in children. Early identification is critical. Through funding from PCORI, the project team developed a child abuse clinical decision support (CA-CDS) system in the electronic health record (EHR) that helps medical providers identify and evaluate child maltreatment. This system is now used in more than 10 healthcare systems in the United States. The goal is for CA-CDS to be widely available and to decrease morbidity and mortality from child maltreatment. There are two main barriers to this goal. First, providers don’t always respond to recommendations of the CA-CDS. Second, it is challenging for hospitals to evaluate how well the CA-CDS is working.

Proposed Solution to the Problem: To address the first barrier, the team will be working with a behavioral economist (BE) who has expertise in changing physician behavior. To address the second barrier, the team will be working with experts in information technology (IT) to better understand the barriers to developing a data warehouse report (DWR), which is what hospitals need to evaluate their CA-CDS.

Objectives: To increase the likelihood that physicians will follow the recommendations made by CA-CDS by improving the end-user experience and assisting in the development of a streamlined process for hospital systems to develop a DWR.

Activities: Activities include evaluation of current CA-CDS systems by a BE who will identify barriers to engagement and develop recommendations for changes. The team will then make these changes and perform a usability evaluation with end users to determine if the changes enhance engagement. The team will hold multi-disciplinary meetings with IT experts and ED providers to identify barriers to DWR development and then develop a new section for the preexisting toolkit based on the findings.

Projected Outcomes and Outputs:
Short term: Integrate and evaluate changes recommended by the BE and develop a toolkit for development of a DWR. 
Medium term: Use data from this project as supporting data for a subsequent PCORI award for broad dissemination of CA-CDS.
Long term: CA-CDS will be a standard part of the EHR by 2029.

Outputs and deliverables will include a list of changes recommended by the BE, a list of the changes made, the results of the usability evaluations, and integration of this information into the CA-CDS toolkits that already exist for three different EHRs: Cerner, EPIC, and Allscripts. Deliverables also include a new section of the toolkits related to DWR development. These toolkits are available free-of-charge to any hospital system.

Patient and Stakeholder Engagement Plan: The stakeholders/collaborators are part of three groups: non-professional caregivers/former abuse victims, policy-related experts/patient advocacy organizations, and Child Protective Services or healthcare-related professionals. The team is retaining most of the stakeholders from prior PCORI projects and adding new ones based on the topic of this new proposal. The team will continue formal and informal stakeholder engagement through online meetings, strategic planning sessions, and participation in research-related presentations and manuscripts.

Project Collaborators: The success of this project depends on multiple collaborators. Jack Stevens, PhD, (expert in behavioral economics) will collaborate as will IT specialists and ED end users from multiple hospitals. These hospitals have signed letters of support and expressed their willingness to collaborate. The team is grateful for the support of these collaborators, many of whom have been part of the team’s previously funded work.