Dissemination of child abuse clinical decision support: Moving beyond a single electronic health record

Abstract

Background: Child maltreatment is a leading cause of pediatric morbidity and mortality. We previously reported on development and implementation of a child abuse clinical decision support system (CA-CDSS) in the Cerner electronic health record (EHR). Our objective was to develop a CA-CDSS in two different EHRs.

Methods: Using the CA-CDSS in Cerner as a template, CA-CDSSs were developed for use in four hospitals in the Northwell Health system who use Allscripts and two hospitals in the University of Wisconsin health system who use Epic. Each system had a combination of triggers, alerts and child abuse-specific order sets. Usability evaluation was done prior to launch of the CA-CDSS.

Results: Over an 18-month period, a CA-CDSS was embedded into Epic and Allscripts at two hospital systems. The CA-CDSSs vary significantly from each other in terms of the type of triggers which were able to be used, the type of alert, the ability of the alert to link directly to child abuse-specific order sets and the order sets themselves.

Conclusions: Dissemination of CA-CDSS from one EHR into the EHR in other health care systems is possible but time-consuming and needs to be adapted to the strengths and limitations of the specific EHR. Site-specific usability evaluation, buy-in of multiple stakeholder groups and significant information technology support are needed. These barriers limit scalability and widespread dissemination of CA-CDSS.

Keywords: Child abuse; Child maltreatment; Clinical decision support; Electronic health record; Physical abuse.

Figure 1a:

Screenshot of the child abuse screen (CAS) used in the Emergency Departments in participating EDs at Northwell Health.

Figure 1b:

The screenshot for the CAS used in EDs at the University of Wisconsin when the nurse selects that the child can cruise.

Figure 1c:

University of Wisconsin’s alternative questions for when the nurse selects that the child does not cruise.

Figure 2a:

Screenshot of Northwell Health acknowledgement/static alert within the ED provider note.

Figure 2b:

Northwell Health’s status board alert color change and pop-up text when hovering on the status tracking board over a patient that triggered the clinical decision support system.

Figure 2c:

Screenshot of the Best Practice Alert at University of Wisconsin if the chief complaint is the trigger.

Figure 3a:

Screenshot of the order set subphases of the physical abuse order set at Northwell Health.

Figure 3b:

A screenshot of Northwell Health’s ‘bruise in a patient less than 6 months old’ subphase.

Figure 3c:

Screenshot of the ‘bruise in a child 6–24 months of age’ subphase’s laboratory orders at the University of Wisconsin.

Figure 3d:

Screenshot of the ‘bruise in a child 6–24 months of age’ subphase’s radiographic and Consult Orders at the University of Wisconsin.

Figure 4a:

Flow chart depicting the functioning of the CA-CDSS at UW

Figure 4b:

Flow chart depicting the functioning of the CA-CDSS of NW