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Supporting Clinicians to Improve Decision Making and Patients’ Care

AHRQ’s Digital Healthcare Research Program funds research to support clinicians and other healthcare professionals in improving their ability to provide optimal health services to their patients. In 2020, a total of $65.3 million was invested in research projects to support technology-enabled decision making and reducing provider burden. Read more about how our research improves decision making in tandem with improving the experience of health professionals who use electronic health records (EHRs) and other digital healthcare technology.

 

Clinical Decision Making

Improving clinical decision making is dependent on clinicians’ ability to access the most relevant, accurate, and recent information to make evidence-based decisions regarding a patient’s healthcare. Integrating evidence-based clinical decision support (CDS) seamlessly into care helps clinicians by delivering the right information to the correct location and at the right time, so that clinicians can make the best care decisions. When well developed and implemented, CDS uses patient-specific data and relies on evidence-based findings to improve health and lead to the best possible outcomes.

 

Dr. Sheila Maria Gephart and a research-based team at the University of Arizona integrated a previously developed CDS into providers’ workflow in neonatal intensive care units to identify necrotizing enterocolitis (NEC) in premature infants. Researchers designed the NEC-Zero intervention to engage families and support team-based care and widespread adoption of evidence-based best practices for NEC prevention. The tool showed high rates of utilization and demonstrated potential for standardized clinical use, which the research team hopes will improve clinical care processes and neonatal outcomes.

 

EHRs have the potential to improve clinicians' diagnosis and treatment of obesity by providing tools such as CDS reminders. Yet, much of the CDS development, research, and funding focus has been on adult patient populations. Therefore, Dr. Mahnoos H. Sharifi and a Yale University-based research team are evaluating different tools within EHRs to assist pediatric care clinicians with providing higher-quality childhood obesity care to slow weight gain in children with obesity.

 

Social Determinants of Health (SDOH)

Social determinants of health (SDOH) are conditions in the environment where people are born, live, learn, work, play, and worship that affect a range of health and quality of life risks and outcomes. An integral part of healthcare delivery involves understanding these social and environmental factors of patients’ lives outside of the healthcare system. Addressing inequities in these conditions, supported in part through the access and use of contextual SDoH data, can help to eliminate health disparities and to improve individual and population health. However, collection and use of contextual SDoH data may not be feasible in a time-constrained visit. The use of integrated digital health IT tools can support the collection of SDoH data, including the following AHRQ-funded research:

 

Dr. Andrea Wallace and team at the University of Utah evaluated the integration of an electronic social needs screener into the emergency department (ED) workflow. This screener was designed to identify patients in need of referrals to non-emergency, community-based resources such as food, transportation, or housing assistance. The research team partnered with the United Way of Utah’s 211 service to facilitate referrals and found that the screener implementation did not pose significant technological, time, or cost barriers. Although only a small portion of patients with reported social needs ultimately received community-based services, the research highlights the feasibility and importance of integrating SDoH into ED discharge planning and its potential to reduce unnecessary ED use.

Read Dr. Wallace's Impact Story

 

Health Technology Design

Improving health technology design to support cognitive work and improve usability is a focus of AHRQ-funded research aimed at addressing EHR-related provider burden. The following research explored ways to improve technology design and use, including clinical workflow, communication, cognitive load, and user satisfaction to reduce provider burden:

 

Dr. Deborah Jill Cohen and team at the Oregon Health and Science University examined the informational needs of care teams to inform design principles for supporting health IT management and care coordination. The research team conducted a mixed methods study of community health center clinicians and clinical teams to identify a range of informational needs regarding patients’ SDoH. Based on these findings, the researchers defined a set of EHR design principles, which was then used to develop an SDoH data collection prototype. Usability testing of the prototype was promising, highlighting its potential to inform clinical decision making when caring for complex patients.

 

Dr. Christopher Harle and research team at Indiana University–Purdue University at Indianapolis developed two user-centered CDS prototypes, Chronic Pain OneSheet and Chronic Pain Treatment Tracker, to support guideline-based clinical decision making for chronic musculoskeletal pain management. The research team conducted a design workshop and usability testing with primary care providers to characterize information use and decision making patterns and found that information accessibility, organized tables, interactivity, and visual cues were imperative design factors. By characterizing common patterns in information availability, information use, and care planning primary care providers relied on during patient visits for chronic pain, the researchers created new EHR-based decision support tools to guide clinicians’ perceptions and judgments of noncancer pain. This led to increased use of guideline-based patient assessment and treatment.

Read Dr. Harle's Impact Story

 

Health IT systems must be designed to support healthcare providers’ cognitive work, workflow, and decision making needs, rather than requiring them to adapt their cognitive work and workflow to meet the system’s requirements. To address this, Dr. Aaron Zachary Hettinger of MedStar Health Research Institute performed a cognitive engineering analysis of ED clinicians’ cognitive needs and workflows to inform the design of health IT for use in complex healthcare environments. The research team conducted EHR data analyses, focus groups, interviews, and observations to identify gaps and challenges in existing health IT and to evaluate prototype usability in a clinical simulation center. The research team identified gaps and challenges related to existing health IT, as well as strategies to improve the methods for developing and testing before implementation.

Read Dr. Hettinger's Impact Story

 

Home healthcare (HHC) agencies have been slow to adopt EHRs and mobile technology. Therefore, transition into HHCs can be challenging because of the absence of, or limits to, an electronic information flow between hospitals and home care agencies. Dr. Paulina Sockolow of Drexel University developed and disseminated a set of IT and EHR design and implementation recommendations for use in HHC transitions. The research team examined nurses’ informational needs, decision making, and workflow during HHC admissions, finding that they often lacked the necessary information prior to entering a patient’s home and instead relied on prior experience to form plan-of-care decisions. This research highlights the need for standardized and interoperable health IT solutions for use in HHC settings.

 

Blood cultures are the only way to diagnose sepsis, a life-threatening bloodstream infection that can affect infants in the pediatric intensive care unit (PICU); however, overuse of blood cultures may result in unnecessary laboratory tests, unnecessary antibiotic use, prolonged hospitalization, and increased healthcare costs. To support clinician’s decision making, Dr. Anping Xie and team at the Johns Hopkins University developed, implemented, and evaluated an EHR-embedded CDS tool to support naturalistic decision making in blood culture utilization among PICU clinicians. The research team examined individual and team cognition and decision making associated with obtaining a blood culture and used those insights to develop the electronic CDS tool iteratively and found that unnecessary blood culture utilization was reduced. The process and architecture used in the development of the CDS tool may be applied to other conditions commonly seen in the PICU, such as venous thromboembolism and traumatic brain injury, and may potentially be generalizable to other healthcare settings.

 

Dr. Tosha Beth Wetterneck of University of Wisconsin–Madison designed and tested Tandem EHR, a prototype to support the cognitive work, such as information searching, situation assessment, problem identification, and problem solving, of primary care physicians and their teams. Through cognitive task analysis, the research team identified providers’ key situation awareness needs, which then informed the design of an EHR prototype. Usability testing of the EHR prototype showed positive results that underscore the need for technology to support the cognitive work of primary care providers and to improve teamwork, provider satisfaction, and quality of patient care.