Appl Clin Inform 2016; 07(02): 534-542
DOI: 10.4338/ACI-2015-10-CR-0144
Case Report
Schattauer GmbH

Clinical Decision Support for a Multicenter Trial of Pediatric Head Trauma

Development, Implementation, and Lessons Learned
Eric Tham
1   Children’s Hospital Colorado, Aurora, CO
2   University of Colorado, Denver, CO
,
Marguerite Swietlik
1   Children’s Hospital Colorado, Aurora, CO
,
Sara Deakyne
1   Children’s Hospital Colorado, Aurora, CO
,
Jeffrey M. Hoffman
3   Department Pediatrics, Section of Emergency Medicine, Nationwide Children’s Hospital, Columbus, OH
4   Ohio State University College of Medicine, Columbus, OH
,
Robert W. Grundmeier
5   Center for Biomedical Informatics, The Children’s Hospital of Philadelphia, Philadelphia, PA
6   Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
,
Marilyn D. Paterno
7   Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA
8   Harvard Medical School, Boston, MA
,
Beatriz H. Rocha
7   Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA
8   Harvard Medical School, Boston, MA
,
Molly H Schaeffer
9   Information Systems, Partners HealthCare System, Boston, MA
,
Deepika Pabbathi
9   Information Systems, Partners HealthCare System, Boston, MA
,
Evaline Alessandrini
10   Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
,
Dustin Ballard
11   Kaiser Permanente, San Rafael Medical Center; Kaiser Permanente, Division of Research, Oakland, CA
,
Howard S. Goldberg
7   Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA
8   Harvard Medical School, Boston, MA
,
Nathan Kuppermann
12   Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento, CA
,
Peter S. Dayan
13   Pediatrics, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY
,
for the Pediatric Emergency Care Applied Research Network (PECARN) › Author Affiliations
American Recovery and Reinvestment Act-Office of the Secretary (ARRA OS): Grant #S02MC19289–01–00. PECARN is supported by the Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB), Emergency Medical Services for Children (EMSC) Program through the following cooperative agreements: U03MC00001, U03MC00003, U03MC00006, U03MC00007, U03MC00008, U03MC22684, and U03MC22685.
Further Information

Correspondence to:

Eric Tham, MD, MS
Seattle Children’s Research Institute
M/S CW8–4
2001 Eighth Avenue
Suite 400
Seattle
WA 98121

Publication History

received: 06 November 2015

accepted: 04 April 2016

Publication Date:
16 December 2017 (online)

 

Summary

Introduction

For children who present to emergency departments (EDs) due to blunt head trauma, ED clinicians must decide who requires computed tomography (CT) scanning to evaluate for traumatic brain injury (TBI). The Pediatric Emergency Care Applied Research Network (PECARN) derived and validated two age-based prediction rules to identify children at very low risk of clinically-important traumatic brain injuries (ciTBIs) who do not typically require CT scans. In this case report, we describe the strategy used to implement the PECARN TBI prediction rules via electronic health record (EHR) clinical decision support (CDS) as the intervention in a multicenter clinical trial.

Methods

Thirteen EDs participated in this trial. The 10 sites receiving the CDS intervention used the Epic® EHR. All sites implementing EHR-based CDS built the rules by using the vendor’s CDS engine. Based on a sociotechnical analysis, we designed the CDS so that recommendations could be displayed immediately after any provider entered prediction rule data. One central site developed and tested the intervention package to be exported to other sites. The intervention package included a clinical trial alert, an electronic data collection form, the CDS rules and the format for recommendations.

Results

The original PECARN head trauma prediction rules were derived from physician documentation while this pragmatic trial led each site to customize their workflows and allow multiple different providers to complete the head trauma assessments. These differences in workflows led to varying completion rates across sites as well as differences in the types of providers completing the electronic data form. Site variation in internal change management processes made it challenging to maintain the same rigor across all sites. This led to downstream effects when data reports were developed.

Conclusions

The process of a centralized build and export of a CDS system in one commercial EHR system successfully supported a multicenter clinical trial.


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Conflicts of Interest

The authors declare that they have no conflicts of interest in the research.

  • References

  • 1 Centers for Disease Control and Prevention. Rates of TBI-related Emergency Department Visits by Age Group- United States. 2001-2010 2014 [updated February 24, 2014; cited 2014 October 22]. Available from: http://www.cdc.gov/traumaticbraininjury/data/rates_ed_byage.html
  • 2 Brenner D. Estimating cancer risks from pediatric CT: going from the qualitative to the quantitative. Pediatric Radiology 2002; 32 (04) 228-231 doi: 10.1007/s00247–002–0671–1.
  • 3 Brenner DJ, Elliston CD, Hall EJ, Berdon WE. Estimated risks of radiation-induced fatal cancer from pediatric CT. American Journal of Roentgenology 2001; 176 (02) 289-296 doi: 10.2214/ajr.176.2.1760289.
  • 4 Pearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, Howe NL, Ronckers CM, Rajaraman P, Craft AW, Parker L, Berrington de AGonzález. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. The Lancet 2012; 380 9840 499-505 doi: http://dx.doi.org/10.1016/S0140–6736(12)60815–0.
  • 5 Hennelly KE, Mannix R, Nigrovic LE, Lee LK, Thompson KM, Monuteaux MC, Proctor M, Schutzman S. Pediatric traumatic brain injury and radiation risks: A clinical decision analysis. The Journal of Pediatrics 2013; 162 (02) 392-397 doi: http://dx.doi.org/10.1016/j.jpeds.2012.07.018.
  • 6 Miglioretti DL, Johnson E, Williams A, Greenlee RT, Weinmann S, Solberg LI, Feigelson HS, Roblin D, Flynn MJ, Vanneman N, Smith-Bindman R. The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA Pediatrics 2013; 167 (08) 700-707 doi: 10.1001/jamapediatrics.2013.311.
  • 7 Mathews JD, Forsythe AV, Brady Z, Butler MW, Goergen SK, Byrnes GB, Giles GG, Wallace AB, Anderson PR, Guiver TA, McGale P, Cain TM, Dowty JG, Bickerstaffe AC, Darby SC. Cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ 2013; 346: f2360 doi: 10.1136/bmj.f2360.
  • 8 Nishijima DK, Yang Z, Urbich M, Holmes JF, Zwienenberg-Lee M, Melnikow J, Kuppermann N. Cost-effectiveness of the PECARN Rules in Children With Minor Head Trauma. Annals of Emergency Medicine 2015; 65 (01) 72-80 e6.
  • 9 Kuppermann N, Holmes JF, Dayan PS, Hoyle JD, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. The Lancet 2009; 374 9696 1160-1170 doi: http://dx.doi.org/10.1016/S0140–6736(09)61558–0.
  • 10 Sheehan B, Nigrovic LE, Dayan PS, Kuppermann N, Ballard DW, Alessandrini E, Bajaj L, Goldberg H, Hoffman J, Offerman SR, Mark DG, Swietlik M, Tham E, Tzimenatos L, Vinson DR, Jones GS, Bakken S. Informing the design of clinical decision support services for evaluation of children with minor blunt head trauma in the emergency department: A sociotechnical analysis. Journal of Biomedical Informatics 2013; 46 (05) 905-913 doi: 10.1016/j.jbi.2013.07.005.
  • 11 Deakyne SJ, Bajaj L, Hoffman J, Alessandrini E, Ballard DW, Norris R, Tzimenatos L, Swietlik M, Tham E, Grundmeier RW, Kuppermann N. Dayan for the Pediatric Emergency Care Applied Research N. Development, evaluation and implementation of chief complaint groupings to activate data collection: A multicenter study of clinical decision support for children with head trauma. Applied Clinical Informatics 2015; 06 (03) 521-535 doi: 10.4338/ACI-2015–02-RA-0019.
  • 12 Boxwala AA, Rocha BH, Maviglia S, Kashyap V, Meltzer S, Kim J, Tsurikova R, Wright A, Paterno MD, Fairbanks A, Middleton B. A multi-layered framework for disseminating knowledge for computer-based decision support. Journal of the American Medical Informatics Association 2011; 18 (Suppl. 01) i132-i139 doi: 10.1136/amiajnl-2011–000334.
  • 13 Goldberg HS, Paterno MD, Rocha BH, Schaeffer M, Wright A, Erickson JL, Middleton B. A highly scalable, interoperable clinical decision support service. Journal of the American Medical Informatics Association 2014; 21 e1 e55-e62 doi: 10.1136/amiajnl-2013–001990.

Correspondence to:

Eric Tham, MD, MS
Seattle Children’s Research Institute
M/S CW8–4
2001 Eighth Avenue
Suite 400
Seattle
WA 98121

  • References

  • 1 Centers for Disease Control and Prevention. Rates of TBI-related Emergency Department Visits by Age Group- United States. 2001-2010 2014 [updated February 24, 2014; cited 2014 October 22]. Available from: http://www.cdc.gov/traumaticbraininjury/data/rates_ed_byage.html
  • 2 Brenner D. Estimating cancer risks from pediatric CT: going from the qualitative to the quantitative. Pediatric Radiology 2002; 32 (04) 228-231 doi: 10.1007/s00247–002–0671–1.
  • 3 Brenner DJ, Elliston CD, Hall EJ, Berdon WE. Estimated risks of radiation-induced fatal cancer from pediatric CT. American Journal of Roentgenology 2001; 176 (02) 289-296 doi: 10.2214/ajr.176.2.1760289.
  • 4 Pearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, Howe NL, Ronckers CM, Rajaraman P, Craft AW, Parker L, Berrington de AGonzález. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. The Lancet 2012; 380 9840 499-505 doi: http://dx.doi.org/10.1016/S0140–6736(12)60815–0.
  • 5 Hennelly KE, Mannix R, Nigrovic LE, Lee LK, Thompson KM, Monuteaux MC, Proctor M, Schutzman S. Pediatric traumatic brain injury and radiation risks: A clinical decision analysis. The Journal of Pediatrics 2013; 162 (02) 392-397 doi: http://dx.doi.org/10.1016/j.jpeds.2012.07.018.
  • 6 Miglioretti DL, Johnson E, Williams A, Greenlee RT, Weinmann S, Solberg LI, Feigelson HS, Roblin D, Flynn MJ, Vanneman N, Smith-Bindman R. The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA Pediatrics 2013; 167 (08) 700-707 doi: 10.1001/jamapediatrics.2013.311.
  • 7 Mathews JD, Forsythe AV, Brady Z, Butler MW, Goergen SK, Byrnes GB, Giles GG, Wallace AB, Anderson PR, Guiver TA, McGale P, Cain TM, Dowty JG, Bickerstaffe AC, Darby SC. Cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ 2013; 346: f2360 doi: 10.1136/bmj.f2360.
  • 8 Nishijima DK, Yang Z, Urbich M, Holmes JF, Zwienenberg-Lee M, Melnikow J, Kuppermann N. Cost-effectiveness of the PECARN Rules in Children With Minor Head Trauma. Annals of Emergency Medicine 2015; 65 (01) 72-80 e6.
  • 9 Kuppermann N, Holmes JF, Dayan PS, Hoyle JD, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. The Lancet 2009; 374 9696 1160-1170 doi: http://dx.doi.org/10.1016/S0140–6736(09)61558–0.
  • 10 Sheehan B, Nigrovic LE, Dayan PS, Kuppermann N, Ballard DW, Alessandrini E, Bajaj L, Goldberg H, Hoffman J, Offerman SR, Mark DG, Swietlik M, Tham E, Tzimenatos L, Vinson DR, Jones GS, Bakken S. Informing the design of clinical decision support services for evaluation of children with minor blunt head trauma in the emergency department: A sociotechnical analysis. Journal of Biomedical Informatics 2013; 46 (05) 905-913 doi: 10.1016/j.jbi.2013.07.005.
  • 11 Deakyne SJ, Bajaj L, Hoffman J, Alessandrini E, Ballard DW, Norris R, Tzimenatos L, Swietlik M, Tham E, Grundmeier RW, Kuppermann N. Dayan for the Pediatric Emergency Care Applied Research N. Development, evaluation and implementation of chief complaint groupings to activate data collection: A multicenter study of clinical decision support for children with head trauma. Applied Clinical Informatics 2015; 06 (03) 521-535 doi: 10.4338/ACI-2015–02-RA-0019.
  • 12 Boxwala AA, Rocha BH, Maviglia S, Kashyap V, Meltzer S, Kim J, Tsurikova R, Wright A, Paterno MD, Fairbanks A, Middleton B. A multi-layered framework for disseminating knowledge for computer-based decision support. Journal of the American Medical Informatics Association 2011; 18 (Suppl. 01) i132-i139 doi: 10.1136/amiajnl-2011–000334.
  • 13 Goldberg HS, Paterno MD, Rocha BH, Schaeffer M, Wright A, Erickson JL, Middleton B. A highly scalable, interoperable clinical decision support service. Journal of the American Medical Informatics Association 2014; 21 e1 e55-e62 doi: 10.1136/amiajnl-2013–001990.