title: Informing the design of clinical decision support services for evaluation of children with minor blunt head trauma in the emergency department: a sociotechnical analysis.
abstract: Integration of clinical decision support services (CDSS) into electronic health records (EHRs) may be integral to widespread dissemination and use of clinical prediction rules in the emergency department (ED). However, the best way to design such services to maximize their usefulness in such a complex setting is poorly understood. We conducted a multi-site cross-sectional qualitative study whose aim was to describe the sociotechnical environment in the ED to inform the design of a CDSS intervention to implement the Pediatric Emergency Care Applied Research Network (PECARN) clinical prediction rules for children with minor blunt head trauma. Informed by a sociotechnical model consisting of eight dimensions, we conducted focus groups, individual interviews and workflow observations in 11 EDs, of which 5 were located in academic medical centers and 6 were in community hospitals. A total of 126 ED clinicians, information technology specialists, and administrators participated. We clustered data into 19 categories of sociotechnical factors through a process of thematic analysis and subsequently organized the categories into a sociotechnical matrix consisting of three high-level sociotechnical dimensions (workflow and communication, organizational factors, human factors) and three themes (interdisciplinary assessment processes, clinical practices related to prediction rules, EHR as a decision support tool). Design challenges that emerged from the analysis included the need to use structured data fields to support data capture and re-use while maintaining efficient care processes, supporting interdisciplinary communication, and facilitating family-clinician interaction for decision-making.
authors.affiliation: Columbia University Medical Center, Faculty Practice Organization, New York, NY, United States. Electronic address: bs584@columbia.edu.
authors.forename: Barbara
authors.initials: B
authors.lastname: Sheehan
authors.forename: Lise E
authors.initials: LE
authors.lastname: Nigrovic
authors.forename: Peter S
authors.initials: PS
authors.lastname: Dayan
authors.forename: Nathan
authors.initials: N
authors.lastname: Kuppermann
authors.forename: Dustin W
authors.initials: DW
authors.lastname: Ballard
authors.forename: Evaline
authors.initials: E
authors.lastname: Alessandrini
authors.forename: Lalit
authors.initials: L
authors.lastname: Bajaj
authors.forename: Howard
authors.initials: H
authors.lastname: Goldberg
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Hoffman
authors.forename: Steven R
authors.initials: SR
authors.lastname: Offerman
authors.forename: Dustin G
authors.initials: DG
authors.lastname: Mark
authors.forename: Marguerite
authors.initials: M
authors.lastname: Swietlik
authors.forename: Eric
authors.initials: E
authors.lastname: Tham
authors.forename: Leah
authors.initials: L
authors.lastname: Tzimenatos
authors.forename: David R
authors.initials: DR
authors.lastname: Vinson
authors.forename: Grant S
authors.initials: GS
authors.lastname: Jones
authors.forename: Suzanne
authors.initials: S
authors.lastname: Bakken
mesh_terms: D002648:Child; D016000:Cluster Analysis; D006259:Craniocerebral Trauma / Q000175:diagnosis*; D003430:Cross-Sectional Studies; D020000:Decision Support Systems, Clinical; D057286:Electronic Health Records; D004636:Emergency Service, Hospital; D006801:Humans
keywords: CDSS; CT; Clinical decision support; ED; Emergency department; Pediatrics; Prediction rules; TBI; Traumatic brain injury; clinical decision support services; computed tomography; emergency department; traumatic brain injury