title: Use of a remote clinical decision support service for a multicenter trial to implement prediction rules for children with minor blunt head trauma.
abstract: OBJECTIVE
  To evaluate the architecture, integration requirements, and execution characteristics of a remote clinical decision support (CDS) service used in a multicenter clinical trial. The trial tested the efficacy of implementing brain injury prediction rules for children with minor blunt head trauma.
  
  
  METHODS
  We integrated the Epic(®) electronic health record (EHR) with the Enterprise Clinical Rules Service (ECRS), a web-based CDS service, at two emergency departments. Patterns of CDS review included either a delayed, near-real-time review, where the physician viewed CDS recommendations generated by the nursing assessment, or a real-time review, where the physician viewed recommendations generated by their own documentation. A backstopping, vendor-based CDS triggered with zero delay when no recommendation was available in the EHR from the web-service. We assessed the execution characteristics of the integrated system and the source of the generated recommendations viewed by physicians.
  
  
  RESULTS
  The ECRS mean execution time was 0.74 ±0.72 s. Overall execution time was substantially different at the two sites, with mean total transaction times of 19.67 and 3.99 s. Of 1930 analyzed transactions from the two sites, 60% (310/521) of all physician documentation-initiated recommendations and 99% (1390/1409) of all nurse documentation-initiated recommendations originated from the remote web service.
  
  
  CONCLUSIONS
  The remote CDS system was the source of recommendations in more than half of the real-time cases and virtually all the near-real-time cases. Comparisons are limited by allowable variation in user workflow and resolution of the EHR clock.
  
  
  CONCLUSIONS
  With maturation and adoption of standards for CDS services, remote CDS shows promise to decrease time-to-trial for multicenter evaluations of candidate decision support interventions.
authors.affiliation: Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA. Electronic address: hgoldberg@partners.org.
authors.forename: Howard S
authors.initials: HS
authors.lastname: Goldberg
authors.affiliation: Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
authors.forename: Marilyn D
authors.initials: MD
authors.lastname: Paterno
authors.affiliation: Center for Biomedical Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Robert W
authors.initials: RW
authors.lastname: Grundmeier
authors.affiliation: Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
authors.forename: Beatriz H
authors.initials: BH
authors.lastname: Rocha
authors.affiliation: Department of Pediatrics, Section of Emergency Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Ohio State University College of Medicine, Columbus, OH, USA.
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Hoffman
authors.affiliation: Research Informatics, Seattle Children's Research Institute, Seattle, WA, USA; Department of Pediatrics, Children's Hospital Colorado, Aurora, CO, USA.
authors.forename: Eric
authors.initials: E
authors.lastname: Tham
authors.affiliation: Department of Pediatrics, Children's Hospital Colorado, Aurora, CO, USA; University of Colorado, Denver, CO, USA.
authors.forename: Marguerite
authors.initials: M
authors.lastname: Swietlik
authors.affiliation: Information Systems, Partners HealthCare System, Boston, MA, USA.
authors.forename: Molly H
authors.initials: MH
authors.lastname: Schaeffer
authors.affiliation: Information Systems, Partners HealthCare System, Boston, MA, USA.
authors.forename: Deepika
authors.initials: D
authors.lastname: Pabbathi
authors.affiliation: Research Informatics, Children's Hospital Colorado, Aurora, CO, USA.
authors.forename: Sara J
authors.initials: SJ
authors.lastname: Deakyne
authors.affiliation: Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento, CA, USA.
authors.forename: Nathan
authors.initials: N
authors.lastname: Kuppermann
authors.affiliation: Pediatrics, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA.
authors.forename: Peter S
authors.initials: PS
authors.lastname: Dayan
mesh_terms: D000293:Adolescent; D001930:Brain Injuries / Q000175:diagnosis*; D019090:Case Management; D002648:Child; D002675:Child, Preschool; D020000:Decision Support Systems, Clinical / Q000706:statistics & numerical data*; D057286:Electronic Health Records / Q000706:statistics & numerical data*; D004636:Emergency Service, Hospital / Q000592:standards*; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D019114:Remote Consultation / Q000706:statistics & numerical data*
keywords: Clinical decision support; Clinical trial; Interoperability; Service-oriented architecture; Standards; Traumatic brain injury