User-Centered Design and Evaluation of Clinical Decision Support to Improve Early Peanut Introduction: Formative Study

Abstract

Background: Peanut allergy has recently become more prevalent. Peanut introduction recommendations have evolved from suggesting peanut avoidance until the age of 3 years to more recent guidelines encouraging early peanut introduction after the Learning Early about Peanut Allergy (LEAP) study in 2015. Guideline adherence is poor, leading to missed care opportunities.

Objective: In this study, we aimed to develop a user-centered clinical decision support (CDS) tool to improve implementation of the most recent early peanut introduction guidelines in the primary care clinic setting.

Methods: We edited the note template of the well-child check (WCC) visits at ages 4 and 6 months with CDS prompts and point-of-care education. Formative and summative usability testing were completed with pediatric residents in a simulated electronic health record (EHR). We estimated task completion rates and perceived usefulness of the CDS in summative testing, comparing a test EHR with and without the CDS.

Results: Formative usability testing with the residents provided qualitative data that led to improvements in the build for both the 4-month and 6-month WCC note templates. During summative usability testing, the CDS tool significantly improved discussion of early peanut introduction at the 4-month WCC visit compared to scenarios without the CDS tool (9/15, 60% with CDS and 0/15, 0% without CDS). All providers except one at the 4-month WCC scenario gave at least an adequate score for the ease of use of the CDS tool for the history of present illness and assessment and plan sections. During the summative usability testing with the 6-month WCC new build note template, providers more commonly provided comprehensive care once obtaining a patient history concerning for an immunoglobulin E-mediated peanut reaction by placing a referral to allergy/immunology (P=.48), prescribing an epinephrine auto-injector (P=.07), instructing on how to avoid peanut products (P<.001), and providing an emergency treatment plan (P=.003) with CDS guidance. All providers gave at least an adequate score for ease of use of the CDS tool in the after-visit summary.

Conclusions: User-centered CDS improved application of early peanut introduction recommendations and comprehensive care for patients who have symptoms concerning for peanut allergy in a simulation.

Keywords: allergy; clinical decision support; early peanut introduction; electronic health records; peanut; peanut introduction; simulation; user-centered design.

Figure 1

Screenshots of (A) the original design of the clinical decision support tool and (B) the edited design after major changes were made based on formative testing. Feedback included comments that the tool needed to include point-of-care education on the definition of an immediate reaction, that the hyperlink was confusing and tedious, and that it was possible to misunderstand the instructions for the after-visit summary.

Figure 2

The ease of use of clinical decision support for 4-month well-child check and 6-month well-child check scenarios for (A) history of present illness, (B) assessment and plan, and (C) after-visit summary. Participants were given 4 different choices, including 1=“not useful,” 2=“adequate,” 3=“useful,” and 4=“very useful.”.